Provider Demographics
NPI:1598806515
Name:DAEHLER, MARCIA KAY (APRN,BC OR CNS)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:KAY
Last Name:DAEHLER
Suffix:
Gender:F
Credentials:APRN,BC OR CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 CONNOLLY ST
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-2724
Mailing Address - Country:US
Mailing Address - Phone:765-743-1894
Mailing Address - Fax:
Practice Address - Street 1:142 SAGAMORE PKWY W
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1569
Practice Address - Country:US
Practice Address - Phone:765-414-5229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28058947A364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP48084Medicare ID - Type Unspecified
IN186810Medicare UPIN