Healthcare Provider Details

I. General information

NPI: 1538250618
Provider Name (Legal Business Name): THERESE LYNN DEFABIS APRN, ANP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THERESE LYNN WALLACE

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 E MARKET ST
INDIANAPOLIS IN
46204-3294
US

IV. Provider business mailing address

PO BOX 211699
EAGAN MN
55121-3699
US

V. Phone/Fax

Practice location:
  • Phone: 866-849-0692
  • Fax: 888-973-8821
Mailing address:
  • Phone: 866-849-0692
  • Fax: 888-973-8821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71000314
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number226556
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0038109
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11037167
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberC-APN.0103422-C-NP
License Number StateCO
# 6
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71000314A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: