Basic Information
| Provider Information | |||||||||
| NPI: | 1356776306 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRICKNELL | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | JOHANNA | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 502 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | LOGANSPORT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469472766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5747322552 | ||||||||
| FaxNumber: | 5747320046 | ||||||||
| Practice Location | |||||||||
| Address1: | 166 SAGAMORE PKWY W | ||||||||
| Address2: | |||||||||
| City: | WEST LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479061569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654972428 | ||||||||
| FaxNumber: | 7654974251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2013 | ||||||||
| LastUpdateDate: | 12/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/12/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71004585A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.