Healthcare Provider Details

I. General information

NPI: 1033695515
Provider Name (Legal Business Name): MRS. TISHA LUCILLE DURBIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4817 N PARKWAY
KOKOMO IN
46901-3940
US

IV. Provider business mailing address

5555 N TACOMA AVE STE 203
INDIANAPOLIS IN
46220-3547
US

V. Phone/Fax

Practice location:
  • Phone: 765-271-8207
  • Fax:
Mailing address:
  • Phone: 317-209-7990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: