Provider Demographics
NPI:1659142685
Name:OVERTON, DUSTIN BROOKE
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:BROOKE
Last Name:OVERTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 E SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:47394-2230
Mailing Address - Country:US
Mailing Address - Phone:765-209-0119
Mailing Address - Fax:
Practice Address - Street 1:2060 N STATE ROAD 1
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE CITY
Practice Address - State:IN
Practice Address - Zip Code:47327-9436
Practice Address - Country:US
Practice Address - Phone:765-478-5395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71014855A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner