=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275536658
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROL ELLEN ELDRIDGE CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2005
-----------------------------------------------------
Last Update Date | 06/30/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 DIVIDEND DR
-----------------------------------------------------
City | LOGANSPORT
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46947-1572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-722-7407
-----------------------------------------------------
Fax | 574-735-0429
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8003 CASTLEWAY DR
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46250-1946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-576-1333
-----------------------------------------------------
Fax | 317-576-1339
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 71001817A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------