Healthcare Provider Details

I. General information

NPI: 1134530967
Provider Name (Legal Business Name): LISA M. FEDDERKE MIDWIFE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8028 CARNEGIE BLVD STE 300
FORT WAYNE IN
46804-5788
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-425-6650
  • Fax: 260-755-6233
Mailing address:
  • Phone: 260-266-6013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number15865NM
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number09000298
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: