Provider Demographics
NPI:1336301290
Name:EBERLE, AMY D
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:D
Last Name:EBERLE
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 1:1251 W KEM RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2561
Mailing Address - Country:US
Mailing Address - Phone:765-662-4107
Mailing Address - Fax:765-651-7305
Practice Address - Street 1:1251 W KEM RD
Practice Address - Street 2:SUITE A
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2561
Practice Address - Country:US
Practice Address - Phone:765-662-4107
Practice Address - Fax:765-651-7305
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28092879A163W00000X, 163WL0100X, 163WP1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP1700XNursing Service ProvidersRegistered NursePerinatal
No163W00000XNursing Service ProvidersRegistered Nurse
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200494920Medicaid