Healthcare Provider Details

I. General information

NPI: 1356349864
Provider Name (Legal Business Name): REGINA MACY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REGINA L CHRISTIANSEN

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 10/25/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2651 E DISCOVERY PKWY
BLOOMINGTON IN
47408-9059
US

IV. Provider business mailing address

PO BOX 1329
BLOOMINGTON IN
47402-1329
US

V. Phone/Fax

Practice location:
  • Phone: 812-353-3719
  • Fax: 812-353-3713
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number71004268A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: