1467747014 NPI number — MISS DEIDRE A COFFEY FNP

Table of content: MISS DEIDRE A COFFEY FNP (NPI 1467747014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467747014 NPI number — MISS DEIDRE A COFFEY FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COFFEY
Provider First Name:
DEIDRE
Provider Middle Name:
A
Provider Name Prefix Text:
MISS
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:
1467747014
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
707 E CEDAR ST
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46617-2057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-472-6700
Provider Business Mailing Address Fax Number:
574-335-0760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1025 WIDENER LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-335-7600
Provider Business Practice Location Address Fax Number:
574-335-0734
Provider Enumeration Date:
06/12/2011

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: 363LF0000X , with the licence number:  28133609A , 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: P01056325 . This is a "RR PTAN (MIAMI LOCATION)" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000878282 . This is a "BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000719214 . This is a "BCBS - BREMEN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000996356 . This is a "BCBS (MIAMI LOCATION)" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 201025560 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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