Provider Demographics
NPI:1497336176
Name:EGENOLF, MARYAM (NP)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:EGENOLF
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARYAM
Other - Middle Name:
Other - Last Name:ELGHOUCHE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2651 E DISCOVERY PKWY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-9059
Practice Address - Country:US
Practice Address - Phone:812-918-3400
Practice Address - Fax:812-335-7371
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF421487-01363LW0102X
IN71012571A363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty