Provider Demographics
NPI:1467747014
Name:COFFEY, DEIDRE A (FNP)
Entity Type:Individual
Prefix:MISS
First Name:DEIDRE
Middle Name:A
Last Name:COFFEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 E CEDAR ST
Mailing Address - Street 2:STE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-472-6700
Mailing Address - Fax:574-335-0760
Practice Address - Street 1:1025 WIDENER LN
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614
Practice Address - Country:US
Practice Address - Phone:574-335-7600
Practice Address - Fax:574-335-0734
Is Sole Proprietor?:No
Enumeration Date:2011-06-12
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28133609A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01056325OtherRR PTAN (MIAMI LOCATION)
IN000000878282OtherBCBS
IN000000719214OtherBCBS - BREMEN
IN000000996356OtherBCBS (MIAMI LOCATION)
IN201025560Medicaid
INM400050248Medicare PIN
IN25730003 (MIAMI)Medicare PIN
INP01056325OtherRR PTAN (MIAMI LOCATION)