Basic Information
| Provider Information | |||||||||
| NPI: | 1487047965 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | BOBBIE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502805 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3125 S SCATTERFIELD RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460131803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652984311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2015 | ||||||||
| LastUpdateDate: | 09/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71005471A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 201289090 | 05 | IN | MEDICAID | P01512390 | 01 | IN | RR MEDICARE | OTHER | 71005471A | 01 | IN | INDIANA APN LICENSE | OTHER | 28142824A | 01 | IN | RN IN LICENSE | OTHER |