Healthcare Provider Details

I. General information

NPI: 1760335368
Provider Name (Legal Business Name): MARY ELLEN L. STROCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ELLEN L. WORDEN

II. Dates (important events)

Enumeration Date: 02/16/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11104 PARKVIEW CIRCLE DR STE 310
FORT WAYNE IN
46845-1733
US

IV. Provider business mailing address

416 E MAUMEE ST
ANGOLA IN
46703-2015
US

V. Phone/Fax

Practice location:
  • Phone: 260-266-5230
  • Fax: 260-452-5972
Mailing address:
  • Phone: 260-667-5131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10005258A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: