Provider Demographics
NPI:1225658644
Name:ILLINGWORTH, DALE A
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:A
Last Name:ILLINGWORTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 RIBBON DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-8167
Mailing Address - Country:US
Mailing Address - Phone:317-652-6667
Mailing Address - Fax:
Practice Address - Street 1:3621 RIBBON DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-8167
Practice Address - Country:US
Practice Address - Phone:317-652-6667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-26
Last Update Date:2020-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty