Healthcare Provider Details

I. General information

NPI: 1336828904
Provider Name (Legal Business Name): EMILY M PROVOST NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMILY M SCHRICK

II. Dates (important events)

Enumeration Date: 07/12/2023
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 SE 4TH ST
EVANSVILLE IN
47708-1607
US

IV. Provider business mailing address

PO BOX 3366
EVANSVILLE IN
47732-3366
US

V. Phone/Fax

Practice location:
  • Phone: 812-426-9311
  • Fax: 812-426-9839
Mailing address:
  • Phone: 812-426-9311
  • Fax: 812-426-9839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number28240747A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: