Healthcare Provider Details

I. General information

NPI: 1780244970
Provider Name (Legal Business Name): CHASTITY RANAE FREDERICK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHASTITY RANAE RUSS

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL LN STE 300
DANVILLE IN
46122-2000
US

IV. Provider business mailing address

1000 E MAIN ST
DANVILLE IN
46122-1948
US

V. Phone/Fax

Practice location:
  • Phone: 317-456-9064
  • Fax: 317-386-5468
Mailing address:
  • Phone: 317-745-4451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71009115A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: