Healthcare Provider Details

I. General information

NPI: 1003159997
Provider Name (Legal Business Name): DEACONESS CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2013
Last Update Date: 08/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 N ELM ST
HENDERSON KY
42420-2712
US

IV. Provider business mailing address

PO BOX 1510
EVANSVILLE IN
47706-1510
US

V. Phone/Fax

Practice location:
  • Phone: 270-827-4596
  • Fax: 270-826-2838
Mailing address:
  • Phone: 270-827-4596
  • Fax: 270-826-2838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

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