Provider Demographics
NPI:1245230176
Name:TRUMP, AMBER DAWN (MSPT, CLT-LANA)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:DAWN
Last Name:TRUMP
Suffix:
Gender:F
Credentials:MSPT, CLT-LANA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1550
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-9350
Mailing Address - Country:US
Mailing Address - Phone:888-434-2314
Mailing Address - Fax:
Practice Address - Street 1:411 S WHITLOCK ST
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:IN
Practice Address - Zip Code:46506-1626
Practice Address - Country:US
Practice Address - Phone:574-546-1930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008322A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000215756OtherANTHEM PIN NUMBER
IN228690AMedicare ID - Type UnspecifiedPROVIDER NUMBER
IN000000215756OtherANTHEM PIN NUMBER