Individual
NICOLE LEIGH FORNALIK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
8040 CLEARVISTA PKWY STE 490, INDIANAPOLIS, IN 46256-5604
(317) 621-5450
(317) 621-5453
Mailing address
6626 E 75TH ST STE 500, INDIANAPOLIS, IN 46250-2890
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
10000784A
IN
363AM0700X
Medical Physician Assistant
10000784A
IN
363AS0400X
Surgical Physician Assistant
10000784A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
300007442
—
IN
Enumeration date
07/05/2006
Last updated
07/15/2025
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