Provider Demographics
NPI:1003136011
Name:NORDSTROM, EMMA JOY (MD)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:JOY
Last Name:NORDSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:EMMA
Other - Middle Name:JOY
Other - Last Name:HAMMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2605 N LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2705 N LEBANON ST STE 300
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-8622
Practice Address - Country:US
Practice Address - Phone:765-485-8649
Practice Address - Fax:765-485-8650
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01070698A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201088750Medicaid
182790002OtherMEDICARE PTAN