MEDICARE: DEVON LORAE MORTLAND

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	163WG0000X	General Practice Registered Nurse	28233644A	IN
2	363L00000X	Nurse Practitioner	71009894A	IN

General Provider Information

NPI Number	:	1912545021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEVON LORAE MORTLAND

Provider Business Mailing Address
First Line	:	1313 W MCGALLIARD RD
Second Line	:
City	:	MUNCIE
State	:	IN
Zip	:	47303-1774
Country	:	US
Telephone Number	:	765-287-8460
Fax Number	:

Provider Business Practice Location Address
First Line	:	1313 W MCGALLIARD RD
Second Line	:
City	:	MUNCIE
State	:	IN
Zip	:	47303-1774
Country	:	US
Telephone Number	:	765-287-8460
Fax Number	:	765-287-8920

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

Provider Enumeration Date	:	12/19/2019
Last Update Date	:	03/11/2020

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Directions to “ DEVON LORAE MORTLAND ” Practice Location

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