Provider Demographics
NPI:1629009790
Name:FEGENBUSH, CAROLYN R (ARNP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:R
Last Name:FEGENBUSH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 MARKET ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47111-9535
Mailing Address - Country:US
Mailing Address - Phone:812-503-5100
Mailing Address - Fax:770-573-9513
Practice Address - Street 1:1802 E 10TH ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-6016
Practice Address - Country:US
Practice Address - Phone:812-288-2488
Practice Address - Fax:770-573-9513
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001579A207QA0401X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2823492000OtherPASSPORT ADVANTAGE
IN200451720Medicaid
50014111OtherPASSPORT
KY78010824Medicaid
P00424435OtherRAILROAD MEDICARE
IN200451720Medicaid
KY0957302Medicare PIN