Healthcare Provider Details

I. General information

NPI: 1164640884
Provider Name (Legal Business Name): BARBARA JANE HERIC FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 03/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6615 S BOUNDARY RD
PORTAGE IN
46368-1373
US

IV. Provider business mailing address

6615 S BOUNDARY RD
PORTAGE IN
46368-1373
US

V. Phone/Fax

Practice location:
  • Phone: 219-787-8662
  • Fax:
Mailing address:
  • Phone: 219-787-8662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71001524A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: