Provider Demographics
NPI:1164084133
Name:RUFFIN, REGINA CHANNELL
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:CHANNELL
Last Name:RUFFIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1923 W GLEN PARK AVE
Mailing Address - Street 2:
Mailing Address - City:GRIFFITH
Mailing Address - State:IN
Mailing Address - Zip Code:46319-3703
Mailing Address - Country:US
Mailing Address - Phone:219-922-2535
Mailing Address - Fax:
Practice Address - Street 1:1923 W GLEN PARK AVE
Practice Address - Street 2:
Practice Address - City:GRIFFITH
Practice Address - State:IN
Practice Address - Zip Code:46319-3703
Practice Address - Country:US
Practice Address - Phone:219-922-2535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-30
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019415363LF0000X
IN71013320A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.019415Medicaid