Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 71004009A | IN |
NPI | 1003175365 |
---|---|
Provider Name | Nora D Mitiche |
First Address | Indianapolis, IN 46250-2805 |
Second Address | Anderson, IN 46012-4235 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/05/2012 |
Last Update Date | 17/09/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
201074320 | (05) | IN |
P01390902 | MEDICARE RR PTAN (01) | IN |