Provider Demographics
NPI:1093272593
Name:YODER, REGINA LYNN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:LYNN
Last Name:YODER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 CEDAR ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8707
Mailing Address - Fax:574-335-0741
Practice Address - Street 1:221 RED COACH DR
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-8323
Practice Address - Country:US
Practice Address - Phone:574-335-7630
Practice Address - Fax:574-335-0841
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704337445363LP0808X, 363LF0000X
IN71009162A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300034979Medicaid