Basic Information
| Provider Information | |||||||||
| NPI: | 1912545021 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORTLAND | ||||||||
| FirstName: | DEVON | ||||||||
| MiddleName: | LORAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1313 W MCGALLIARD RD | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473031774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652878460 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1313 W MCGALLIARD RD | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473031774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652878460 | ||||||||
| FaxNumber: | 7652878920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2019 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0000X | 28233644A | IN | N | Nursing Service Providers | Registered Nurse | General Practice | 363L00000X | 71009894A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.