Provider Demographics
NPI:1659681344
Name:WITHAM, LINDA G (NP)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:G
Last Name:WITHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:G
Other - Last Name:MISNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
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 1:13100 E 136TH ST
Practice Address - Street 2:STE 1200
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9478
Practice Address - Country:US
Practice Address - Phone:317-688-5200
Practice Address - Fax:317-688-5215
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003450A363LW0102X
IN28132395A363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201013900Medicaid
INM400056234Medicare PIN