Healthcare Provider Details

I. General information

NPI: 1578934402
Provider Name (Legal Business Name): TIMOTHY PRIMROSE NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2015
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 HOLY CROSS PKWY
MISHAWAKA IN
46545-1469
US

IV. Provider business mailing address

707 CEDAR ST STE 405
SOUTH BEND IN
46617-2057
US

V. Phone/Fax

Practice location:
  • Phone: 574-335-4145
  • Fax: 574-335-4146
Mailing address:
  • Phone: 574-335-8707
  • Fax: 574-335-0741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71005880A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number71005880A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: