Healthcare Provider Details

I. General information

NPI: 1780591974
Provider Name (Legal Business Name): EMILY JO PROCTOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 S MAIN ST STE 100
CLINTON IN
47842-2493
US

IV. Provider business mailing address

8130 S DOBERMAN ST
TERRE HAUTE IN
47802-9508
US

V. Phone/Fax

Practice location:
  • Phone: 765-828-1003
  • Fax:
Mailing address:
  • Phone: 812-230-8499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number28248420A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: