Basic Information
| Provider Information | |||||||||
| NPI: | 1528263076 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COUNTRYMAN | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8910 PURDUE RD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462683161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178718811 | ||||||||
| FaxNumber: | 3178718833 | ||||||||
| Practice Location | |||||||||
| Address1: | 6940 MICHIGAN RD | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462682800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172662901 | ||||||||
| FaxNumber: | 3172662916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2007 | ||||||||
| LastUpdateDate: | 12/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP 60167721 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 71001936A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 200866670 | 05 | IN | MEDICAID |