MEDICARE: ANITA LOUISE DOCTOR NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	71002180A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000490404	OTHER	IN	ANTHEM BLUE CROSS

General Provider Information

NPI Number	:	1740204270
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANITA LOUISE DOCTOR NP

Provider Business Mailing Address
First Line	:	14303 W CEDAR LAKE DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9642
Country	:	US
Telephone Number	:	260-438-8863
Fax Number	:

Provider Business Practice Location Address
First Line	:	14303 W CEDAR LAKE DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9642
Country	:	US
Telephone Number	:	260-438-8863
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2006
Last Update Date	:	03/17/2018

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Directions to “ ANITA LOUISE DOCTOR NP” Practice Location

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