Provider Demographics
NPI:1477659605
Name:KARK, DEBORAH LOUISE (NP)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LOUISE
Last Name:KARK
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 1:300 N MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-3281
Mailing Address - Country:US
Mailing Address - Phone:219-663-4877
Mailing Address - Fax:219-663-4877
Practice Address - Street 1:300 N MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-3281
Practice Address - Country:US
Practice Address - Phone:219-663-4877
Practice Address - Fax:219-663-4877
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000240A363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ2007002OtherMEDICARE#
IN200118190Medicaid
ININ2007002OtherMEDICARE#