Healthcare Provider Details

I. General information

NPI: 1356992077
Provider Name (Legal Business Name): ANDREA LYNN DETAMORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2019
Last Update Date: 09/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 N WABASH
MARION IN
46952-2612
US

IV. Provider business mailing address

330 N WABASH STE G20
MARION IN
46952
US

V. Phone/Fax

Practice location:
  • Phone: 765-660-6900
  • Fax:
Mailing address:
  • Phone: 765-660-7616
  • Fax: 765-651-7313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number28198394A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2819394A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: