Provider Demographics
NPI:1740204270
Name:DOCTOR, ANITA LOUISE (NP)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:LOUISE
Last Name:DOCTOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14303 W CEDAR LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9642
Mailing Address - Country:US
Mailing Address - Phone:260-438-8863
Mailing Address - Fax:
Practice Address - Street 1:14303 W CEDAR LAKE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-9642
Practice Address - Country:US
Practice Address - Phone:260-438-8863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002180A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000490404OtherANTHEM BLUE CROSS
IN000000490404OtherANTHEM BLUE CROSS
INQ75431Medicare UPIN