Provider Demographics
NPI:1467722249
Name:ETGEN, JOELYN M (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:JOELYN
Middle Name:M
Last Name:ETGEN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:JOELYN
Other - Middle Name:MARIE
Other - Last Name:ETGEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP-C
Mailing Address - Street 1:770 E DUPONT RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-2056
Mailing Address - Country:US
Mailing Address - Phone:260-451-8242
Mailing Address - Fax:
Practice Address - Street 1:770 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-2056
Practice Address - Country:US
Practice Address - Phone:260-451-8242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA 13375-NP363LF0000X
IN71003840A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201047530Medicaid
OH0076586Medicaid
12330800OtherCAQH
INM40062495OtherPTAN
OHH149901OtherPTAN