Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0005X | Nurse Practitioner - Neonatal (Critical Care) | 71002781A | IN |
NPI | 1124279575 |
---|---|
Provider Name | Amanda H Ferguson-Macy |
First Address | Lafayette, IN 47903-5545 |
Second Address | Lafayette, IN 47904-2477 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/10/2008 |
Last Update Date | 17/11/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000610507 | ANTHEM PROVIDER NUMBER (01) | IN |
200936930 | (05) | IN |