Healthcare Provider Details

I. General information

NPI: 1780543918
Provider Name (Legal Business Name): DEACONESS CLINC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2026
Last Update Date: 01/22/2026
Certification Date: 01/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4840 S MAPLE TREE DR
PRINCETON IN
47670-9277
US

IV. Provider business mailing address

4840 S MAPLE TREE DR
PRINCETON IN
47670-9277
US

V. Phone/Fax

Practice location:
  • Phone: 812-387-4444
  • Fax: 812-387-4445
Mailing address:
  • Phone: 812-387-4444
  • Fax: 812-387-4445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHERYL ANNETTE WATHEN
Title or Position: CFO
Credential:
Phone: 812-450-3296