Healthcare Provider Details

I. General information

NPI: 1952913279
Provider Name (Legal Business Name): JOSHUA DANIEL AVERY FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2020
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 N DETROIT ST
LAGRANGE IN
46761-1154
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-463-4896
  • Fax: 260-463-5242
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71010287A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: