1184142721 NPI number — TYNE MARIE SIMPSON FNP

Table of content: TYNE MARIE SIMPSON FNP (NPI 1184142721)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184142721 NPI number — TYNE MARIE SIMPSON FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMPSON
Provider First Name:
TYNE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

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

NPI Number Information

NPI Number:
1184142721
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3245 HEALTH DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANGER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46530-1380
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-647-2127
Provider Business Mailing Address Fax Number:
574-237-6069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 NAVARRE PL
Provider Second Line Business Practice Location Address:
STE 4440
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46601-1171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-647-5300
Provider Business Practice Location Address Fax Number:
574-647-5305
Provider Enumeration Date:
09/05/2017

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: 163W00000X , with the licence number:  28172954 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 71007418A , 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)

  • Identifier: 300006126 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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