Healthcare Provider Details

I. General information

NPI: 1760633267
Provider Name (Legal Business Name): PATRICIA R FETTIG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10731 N STATE ROAD 13
ELWOOD IN
46036-8874
US

IV. Provider business mailing address

9615 E 148TH ST SUITE 1
NOBLESVILLE IN
46060-4360
US

V. Phone/Fax

Practice location:
  • Phone: 765-552-5009
  • Fax: 765-552-8347
Mailing address:
  • Phone: 317-587-0500
  • Fax: 317-674-0060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71002768A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: