Healthcare Provider Details

I. General information

NPI: 1942305628
Provider Name (Legal Business Name): CAROL RUTH GOUKER ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 W. 10TH STREET
INDIANAPOLIS IN
46202
US

IV. Provider business mailing address

1481 W. 10TH STREET
INDIANAPOLIS IN
46202
US

V. Phone/Fax

Practice location:
  • Phone: 317-988-2969
  • Fax: 317-988-2422
Mailing address:
  • Phone: 317-988-2969
  • Fax: 317-988-2422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71000118B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: