Provider Demographics
NPI:1497136865
Name:MOSBRUCKER, DORINDA SUE (NP-C)
Entity Type:Individual
Prefix:
First Name:DORINDA
Middle Name:SUE
Last Name:MOSBRUCKER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 E DUPONT RD STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1609
Mailing Address - Country:US
Mailing Address - Phone:260-748-3650
Mailing Address - Fax:765-622-0126
Practice Address - Street 1:2512 E DUPONT RD STE 200
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825
Practice Address - Country:US
Practice Address - Phone:260-748-3650
Practice Address - Fax:260-748-3651
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005500A363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP02018855OtherRAILROAD MEDICARE
IN201301240Medicaid
IN1090735OtherINDIANA BCBS