Basic Information
| Provider Information | |||||||||
| NPI: | 1942924766 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEACONESS CLINIC, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1510 | ||||||||
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| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477061510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124506815 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1355 US HIGHWAY 41A S | ||||||||
| Address2: | |||||||||
| City: | DIXON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424099447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706399101 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2022 | ||||||||
| LastUpdateDate: | 09/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | WATHEN | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | ANNETTE | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8124503296 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.