Healthcare Provider Details

I. General information

NPI: 1750570156
Provider Name (Legal Business Name): TINA MARIE BAXTER GNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 W 8TH ST
ANDERSON IN
46016-1206
US

IV. Provider business mailing address

720 W 8TH ST
ANDERSON IN
46016-1206
US

V. Phone/Fax

Practice location:
  • Phone: 765-288-1110
  • Fax: 765-393-3458
Mailing address:
  • Phone: 765-288-1110
  • Fax: 765-393-3458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number71002513A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: