Healthcare Provider Details

I. General information

NPI: 1780322404
Provider Name (Legal Business Name): HARLEY DANIELLE THOMAS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HARLEY ROGERS

II. Dates (important events)

Enumeration Date: 05/23/2022
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S LANDMARK AVE
BLOOMINGTON IN
47403-3239
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 812-355-2750
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number28250876A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number71012677A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: