Basic Information
| Provider Information | |||||||||
| NPI: | 1598134512 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITACRE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | RN, APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6655 E US HIGHWAY 36 | ||||||||
| Address2: | |||||||||
| City: | AVON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461238923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887141927 | ||||||||
| FaxNumber: | 3172720807 | ||||||||
| Practice Location | |||||||||
| Address1: | 6655 E US HIGHWAY 36 | ||||||||
| Address2: | |||||||||
| City: | AVON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461238923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887141927 | ||||||||
| FaxNumber: | 3172720807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2015 | ||||||||
| LastUpdateDate: | 11/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71005740A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0808X | 71005740A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.