Provider Demographics
NPI:1407424708
Name:UPDIKE, FAWN (RN, MSN)
Entity Type:Individual
Prefix:
First Name:FAWN
Middle Name:
Last Name:UPDIKE
Suffix:
Gender:F
Credentials:RN, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:46750-3524
Mailing Address - Country:US
Mailing Address - Phone:812-371-4311
Mailing Address - Fax:
Practice Address - Street 1:1340 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:IN
Practice Address - Zip Code:46750-3524
Practice Address - Country:US
Practice Address - Phone:812-371-4311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28121898A163WI0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WI0600XNursing Service ProvidersRegistered NurseInfection ControlGroup - Single Specialty