Healthcare Provider Details

I. General information

NPI: 1417748559
Provider Name (Legal Business Name): DEACONESS CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2025
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 E 22ND ST
HUNTINGBURG IN
47542-8964
US

IV. Provider business mailing address

PO BOX 631767
CINCINNATI OH
45263-2767
US

V. Phone/Fax

Practice location:
  • Phone: 812-683-3612
  • Fax: 812-683-2819
Mailing address:
  • Phone: 812-450-6879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHERYL ANNETTE WATHEN
Title or Position: CFO
Credential:
Phone: 812-450-3296