Healthcare Provider Details

I. General information

NPI: 1265021406
Provider Name (Legal Business Name): WILLARD KEITH CUPP III PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 11/03/2023
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 SIMPSON AVE
ELKHART IN
46516-4666
US

IV. Provider business mailing address

236 SIMPSON AVE
ELKHART IN
46516-4666
US

V. Phone/Fax

Practice location:
  • Phone: 574-293-0052
  • Fax:
Mailing address:
  • Phone: 574-968-2461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71010753A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: