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General NPI Number Information
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NPI Number | 1174064562
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Entity Type | Individual
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Provider Name | SUSAN REBEKAH DEFRAIN NP-C
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Gender | Female
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Dates
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Enumeration Date | 03/17/2017
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Last Update Date | 12/05/2025
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Provider Practice Location Address
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Address Line | 5910 HOMESTEAD RD
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City | FORT WAYNE
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State | IN
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Zip | 46814-4202
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Country | US
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Telephone | 260-435-3222
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Fax |
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Provider Business Mailing Address
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Address Line | 5910 HOMESTEAD RD
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City | FORT WAYNE
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State | IN
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Zip | 46814-4202
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Country | US
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Telephone | 260-435-3222
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | AG02170207
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License Number State | IN
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