Healthcare Provider Details

I. General information

NPI: 1619336096
Provider Name (Legal Business Name): DINA M MOURICE AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DINA M HERMINA

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5525 GEORGETOWN RD STE F
INDIANAPOLIS IN
46254-3717
US

IV. Provider business mailing address

5525 GEORGETOWN RD STE F
INDIANAPOLIS IN
46254-3717
US

V. Phone/Fax

Practice location:
  • Phone: 317-293-9039
  • Fax: 317-293-9049
Mailing address:
  • Phone: 317-293-9039
  • Fax: 317-293-9049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71006366A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: