Provider Demographics
NPI:1619967098
Name:HINES, ELIZABETH ANN (APRN,BC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:HINES
Suffix:
Gender:F
Credentials:APRN,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2723 S 7TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-3584
Mailing Address - Country:US
Mailing Address - Phone:812-238-1730
Mailing Address - Fax:812-242-1565
Practice Address - Street 1:115 S MURPHY AVE
Practice Address - Street 2:SUITE A
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834-8296
Practice Address - Country:US
Practice Address - Phone:812-442-2100
Practice Address - Fax:812-446-4409
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28121880363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201029180Medicaid
INQ17999Medicare UPIN
IN170380DMedicare ID - Type UnspecifiedINDIVIDUAL MCR #
IN170380Medicare ID - Type UnspecifiedGROUP MCR #