Healthcare Provider Details

I. General information

NPI: 1881864866
Provider Name (Legal Business Name): MARY KATHERINE MARIOTTI FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5880 W STATE ROAD 28
TIPTON IN
46072-9116
US

IV. Provider business mailing address

2032 TREVING DR
CICERO IN
46034-9118
US

V. Phone/Fax

Practice location:
  • Phone: 765-557-6097
  • Fax: 765-557-6124
Mailing address:
  • Phone: 317-984-0211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71002763A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: