Healthcare Provider Details

I. General information

NPI: 1740639186
Provider Name (Legal Business Name): ASHLEY MARISA KEIM N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S MADISON ST
MUNCIE IN
47305-2465
US

IV. Provider business mailing address

333 S MADISON ST
MUNCIE IN
47305-2465
US

V. Phone/Fax

Practice location:
  • Phone: 765-281-4257
  • Fax:
Mailing address:
  • Phone: 765-281-4257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number28184582A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: