Healthcare Provider Details

I. General information

NPI: 1225584295
Provider Name (Legal Business Name): PURDUE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 08/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 E COLISEUM BLVD WU 234
FORT WAYNE IN
46805-1445
US

IV. Provider business mailing address

2101 E COLISEUM BLVD WU 234
FORT WAYNE IN
46805-1445
US

V. Phone/Fax

Practice location:
  • Phone: 260-481-0400
  • Fax:
Mailing address:
  • Phone: 260-481-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number28079817
License Number StateIN

VIII. Authorized Official

Name: CREASIE E HILL
Title or Position: HEALTH CLINIC OFFICE MANAGER
Credential:
Phone: 206-481-6967