Basic Information
| Provider Information | |||||||||
| NPI: | 1093322505 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DECKER | ||||||||
| FirstName: | AMY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 S LANDMARK AVE | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474033239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123303689 | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 S LANDMARK AVE | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474033239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123553255 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2020 | ||||||||
| LastUpdateDate: | 08/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 28212313A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 71010923A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.