Basic Information
Provider Information | |||||||||
NPI: | 1912432832 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GREENE COUNTY HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8754 N 1380 W | ||||||||
Address2: |   | ||||||||
City: | JASONVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 474386063 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8128477005 | ||||||||
FaxNumber: | 8128475309 | ||||||||
Practice Location | |||||||||
Address1: | 1210 N 1000 W | ||||||||
Address2: |   | ||||||||
City: | LINTON | ||||||||
State: | IN | ||||||||
PostalCode: | 474415013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8126994153 | ||||||||
FaxNumber: | 8126994271 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/28/2017 | ||||||||
LastUpdateDate: | 04/28/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | INMAN | ||||||||
AuthorizedOfficialFirstName: | TARYN | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8126994153 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71007062A | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.