MEDICARE: MISS ANNE LOUISE HEINOLD APN FNP

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	209004835	IL
2	363L00000X	Nurse Practitioner	28221087A	IN
3	363LF0000X	Family Nurse Practitioner	71005430A	IN

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	M47140187	OTHER	IN	MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1205820552
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS ANNE LOUISE HEINOLD APN FNP

Provider Business Mailing Address
First Line	:	PO BOX 781076
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48278-1076
Country	:	US
Telephone Number	:	317-528-4800
Fax Number	:	317-865-1479

Provider Business Practice Location Address
First Line	:	1701 S CREASY LN
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47905-4972
Country	:	US
Telephone Number	:	765-502-4917
Fax Number	:	765-502-4023

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2005
Last Update Date	:	05/02/2023

1701 S CREASY LN RM 1K71
LAFAYETTE, IN
47905-4972

Practice Phone: 765-502-4499
Practice Fax: