Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | 01063222A | IN |
NPI | 1013032325 |
---|---|
Provider Name | Mrs. Angela Sue Fornkohl Blum |
First Address | New Castle, IN 47362-0426 |
Second Address | New Castle, IN 47362-4319 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/03/2007 |
Last Update Date | 14/01/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000519955 | ANTHEM (01) | IN |
200861200 | (05) | IN |