Basic Information
Provider Information | |||||||||
NPI: | 1518272582 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ORR | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CPNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KINDER | ||||||||
OtherFirstName: | AMY | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CPNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 240 N TILLOTSON AVE | ||||||||
Address2: |   | ||||||||
City: | MUNCIE | ||||||||
State: | IN | ||||||||
PostalCode: | 473043988 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7652881928 | ||||||||
FaxNumber: | 7657410310 | ||||||||
Practice Location | |||||||||
Address1: | 3807 S MADISON ST | ||||||||
Address2: |   | ||||||||
City: | MUNCIE | ||||||||
State: | IN | ||||||||
PostalCode: | 473025758 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7657473858 | ||||||||
FaxNumber: | 3177473859 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/13/2010 | ||||||||
LastUpdateDate: | 11/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 71003308A | IN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
ID | Type | State | Issuer | Description | 200992680 | 05 | IN |   | MEDICAID |