Basic Information
| Provider Information | |||||||||
| NPI: | 1396938429 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUNK | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6100 W 96TH ST | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462786005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177151800 | ||||||||
| FaxNumber: | 3177156200 | ||||||||
| Practice Location | |||||||||
| Address1: | 8301 HARCOURT RD | ||||||||
| Address2: | RADIATION ONCOLOGY DEPT, STE 100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462602081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174156783 | ||||||||
| FaxNumber: | 3174156758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2007 | ||||||||
| LastUpdateDate: | 04/30/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71001509A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 000000864920 | 01 | IN | ANTHEM | OTHER | 201216930 | 05 | IN | MEDICAID | 71001509B | 01 | IN | APN CSR | OTHER | MH0926949 | 01 | IN | DEA | OTHER |