Healthcare Provider Details

I. General information

NPI: 1942845854
Provider Name (Legal Business Name): DEACONESS CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 STARLITE DR
HENDERSON KY
42420-6102
US

IV. Provider business mailing address

PO BOX 1510
EVANSVILLE IN
47706-1510
US

V. Phone/Fax

Practice location:
  • Phone: 270-215-3183
  • Fax:
Mailing address:
  • Phone: 812-450-6815
  • Fax: 812-450-6815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

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