Healthcare Provider Details

I. General information

NPI: 1194010322
Provider Name (Legal Business Name): DEANNA MARIE MARCUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 06/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5828 INDEPENDENCE AVE
INDIANAPOLIS IN
46234-3683
US

IV. Provider business mailing address

5828 INDEPENDENCE AVE
INDIANAPOLIS IN
46234-3683
US

V. Phone/Fax

Practice location:
  • Phone: 317-918-4355
  • Fax:
Mailing address:
  • Phone: 317-918-4355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number10-012343-1
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number10-012345-1
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: