Basic Information
Provider Information | |||||||||
NPI: | 1841287299 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PAUNICKA | ||||||||
FirstName: | NANCY | ||||||||
MiddleName: | JANE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN MS-FNP-CS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HOGLUND-PAUNICKA | ||||||||
OtherFirstName: | NANCY | ||||||||
OtherMiddleName: | JANE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN MS-FNP-CS | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1690 | ||||||||
Address2: |   | ||||||||
City: | LA PORTE | ||||||||
State: | IN | ||||||||
PostalCode: | 463521690 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2193262312 | ||||||||
FaxNumber: | 2193262584 | ||||||||
Practice Location | |||||||||
Address1: | 3777 NORTH FRONTAGE ROAD | ||||||||
Address2: |   | ||||||||
City: | MICHIGAN CITY | ||||||||
State: | IN | ||||||||
PostalCode: | 463607694 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2198773880 | ||||||||
FaxNumber: | 2198796365 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/30/2005 | ||||||||
LastUpdateDate: | 11/28/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71000141A | IN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 000000772332 | 01 | IN | ANTHEM BCBS | OTHER | M400075623 | 01 | IN | MEDICARE PTAN | OTHER | 200083140 | 05 | IN |   | MEDICAID |