Provider Demographics
NPI:1508041716
Name:DEGENHARDT, ELISABETH K (RN, MSN)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:K
Last Name:DEGENHARDT
Suffix:
Gender:F
Credentials:RN, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
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 1:5230 E STOP 11 RD STE 300
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6401
Practice Address - Country:US
Practice Address - Phone:317-781-4588
Practice Address - Fax:317-782-4885
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000009C364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN28089558AOtherRN LICENSE
IN200980490Medicaid
IN200980490Medicaid
IN200980490Medicaid