Provider Demographics
NPI:1033787791
Name:WATHEN, TINA (LPN)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:WATHEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LOOGOOTEE
Mailing Address - State:IN
Mailing Address - Zip Code:47553-2107
Mailing Address - Country:US
Mailing Address - Phone:812-709-9391
Mailing Address - Fax:
Practice Address - Street 1:1694 TROY RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-8216
Practice Address - Country:US
Practice Address - Phone:812-254-3800
Practice Address - Fax:812-254-3801
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27054511A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse