Provider Demographics
NPI:1376502922
Name:HARTMAN, AMY J (NP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:J
Last Name:HARTMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57640 BOULDER CT
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-7859
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 E DOUGLAS RD
Practice Address - Street 2:SUITE 408
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1464
Practice Address - Country:US
Practice Address - Phone:574-335-6440
Practice Address - Fax:574-335-0806
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001779363LF0000X
IN71001779A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000341502OtherANTHEM
IN000001006136OtherANTHEM OB/GYN
IN200492340Medicaid
IN187670009Medicare PIN
IN000001006136OtherANTHEM OB/GYN