Provider Demographics
NPI:1689470163
Name:NICKELSON, ALEXA ANN (CNM, WHNP-BC)
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:ANN
Last Name:NICKELSON
Suffix:
Gender:
Credentials:CNM, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 N ELKHART ST
Mailing Address - Street 2:
Mailing Address - City:WAKARUSA
Mailing Address - State:IN
Mailing Address - Zip Code:46573-9729
Mailing Address - Country:US
Mailing Address - Phone:574-390-0241
Mailing Address - Fax:574-393-9943
Practice Address - Street 1:207 N ELKHART ST
Practice Address - Street 2:
Practice Address - City:WAKARUSA
Practice Address - State:IN
Practice Address - Zip Code:46573-9729
Practice Address - Country:US
Practice Address - Phone:574-390-0241
Practice Address - Fax:574-393-9943
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-24
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN104216827363LW0102X
IN28276535A364SW0102X
IN09000490A176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's HealthGroup - Multi-Specialty