Healthcare Provider Details

I. General information

NPI: 1982268546
Provider Name (Legal Business Name): ILA R MASON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ILA R MASON RENEE MASON FNP-C

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2072 N COUNTY ROAD 700 W
RICHLAND IN
47634-9480
US

IV. Provider business mailing address

2072 N COUNTY ROAD 700 W
RICHLAND IN
47634-9480
US

V. Phone/Fax

Practice location:
  • Phone: 812-359-4012
  • Fax: 812-359-4481
Mailing address:
  • Phone: 812-359-4012
  • Fax: 812-359-4481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number71008933A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: