Provider Demographics
NPI:1346679297
Name:MASHIBE, FORTUNATA (CRNA)
Entity Type:Individual
Prefix:
First Name:FORTUNATA
Middle Name:
Last Name:MASHIBE
Suffix:
Gender:F
Credentials:CRNA
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 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:1000 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-1948
Practice Address - Country:US
Practice Address - Phone:317-745-4451
Practice Address - Fax:317-718-6740
Is Sole Proprietor?:No
Enumeration Date:2013-11-01
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28161083A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000847539OtherANTHEM PROVIDER NUMBER
IN201198840Medicaid
IN815500045Medicare PIN
IN201198840Medicaid