1083132690 NPI number — MRS. SALLY MARIE NURSE MS, OTR/L

Table of content: MRS. SALLY MARIE NURSE MS, OTR/L (NPI 1083132690)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083132690 NPI number — MRS. SALLY MARIE NURSE MS, OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NURSE
Provider First Name:
SALLY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS, OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COBB
Provider Other First Name:
SALLY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083132690
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3500 DEPAUW BLVD STE 3070
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46268-6135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-324-0885
Provider Business Mailing Address Fax Number:
765-454-9759

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6635 EAST 21ST STREET
Provider Second Line Business Practice Location Address:
SUITE 100 WEST BUILDING
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46219-2254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-608-2824
Provider Business Practice Location Address Fax Number:
765-454-9759
Provider Enumeration Date:
09/04/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: 31000786A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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