1164738662 NPI number — SHERISE L.E. DEARDORFF PA-C

Table of content: MOLLY KATHERINE CAMERER OD (NPI 1922449487)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164738662 NPI number — SHERISE L.E. DEARDORFF PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEARDORFF
Provider First Name:
SHERISE
Provider Middle Name:
L.E.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DENNY
Provider Other First Name:
SHERISE
Provider Other Middle Name:
L.E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164738662
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11109 PARKVIEW PLAZA DR # 117
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46845-1701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1655 N CASS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WABASH
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46992-9416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-563-2126
Provider Business Practice Location Address Fax Number:
260-569-2494
Provider Enumeration Date:
08/23/2010

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: 363AM0700X , with the licence number:  10001777A , 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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