Provider Demographics
NPI:1275536658
Name:ELDRIDGE, CAROL ELLEN (CNP)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:ELLEN
Last Name:ELDRIDGE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8003 CASTLEWAY DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-1946
Mailing Address - Country:US
Mailing Address - Phone:317-576-1333
Mailing Address - Fax:317-576-1339
Practice Address - Street 1:1700 DIVIDEND DR
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1572
Practice Address - Country:US
Practice Address - Phone:574-722-7407
Practice Address - Fax:574-735-0429
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001817A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200503400Medicaid
000000357698OtherANTHEM BLUE CROSS
IN200503400Medicaid
921430RMedicare ID - Type Unspecified