=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134013006
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA ANN GOUGER ACNPC-AG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2025
-----------------------------------------------------
Last Update Date | 07/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8865 W 400 N STE 175
-----------------------------------------------------
City | MICHIGAN CITY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46360-9010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-877-2225
-----------------------------------------------------
Fax | 219-877-2230
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 781076
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48278-1076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-528-4800
-----------------------------------------------------
Fax | 317-865-1479
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 28184707A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 71016769A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------