Basic Information
| Provider Information | |||||||||
| NPI: | 1346679297 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASHIBE | ||||||||
| FirstName: | FORTUNATA | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5545 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479035545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654488000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461221948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177454451 | ||||||||
| FaxNumber: | 3177186740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2013 | ||||||||
| LastUpdateDate: | 06/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 28161083A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000000847539 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER | 201198840 | 05 | IN | MEDICAID |