Basic Information
Provider Information | |||||||||
NPI: | 1851428585 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOERSTLER | ||||||||
FirstName: | MANDELLE | ||||||||
MiddleName: | DREU | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 568 | ||||||||
Address2: |   | ||||||||
City: | NEW CASTLE | ||||||||
State: | IN | ||||||||
PostalCode: | 473620568 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7655211516 | ||||||||
FaxNumber: | 7655993131 | ||||||||
Practice Location | |||||||||
Address1: | 1000 N 16TH ST STE 240 | ||||||||
Address2: |   | ||||||||
City: | NEW CASTLE | ||||||||
State: | IN | ||||||||
PostalCode: | 473624319 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7655211461 | ||||||||
FaxNumber: | 7655993101 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/28/2007 | ||||||||
LastUpdateDate: | 09/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71002023A | IN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 000000682072 | 01 |   | ANTHEM | OTHER | 0067498 | 05 | OH |   | MEDICAID | 201004400 | 05 | IN |   | MEDICAID |