Provider Demographics
NPI:1093766784
Name:KLINGENBERGER, MARISHA A (NP)
Entity Type:Individual
Prefix:
First Name:MARISHA
Middle Name:A
Last Name:KLINGENBERGER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARISHA
Other - Middle Name:A
Other - Last Name:HORKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 RANDALLIA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4638
Practice Address - Country:US
Practice Address - Phone:260-373-6070
Practice Address - Fax:260-373-6704
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001042A363L00000X
IN71001042363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200332990Medicaid
INP33262Medicare UPIN
IN925060SSSMedicare ID - Type Unspecified