Provider Demographics
NPI:1760089445
Name:HUMBERG, MARA NICOLE (NP)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:NICOLE
Last Name:HUMBERG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:NICOLE
Other - Last Name:LAVELLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1716 HARTFORD ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2138
Mailing Address - Country:US
Mailing Address - Phone:765-742-1567
Mailing Address - Fax:765-429-2700
Practice Address - Street 1:2316 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2971
Practice Address - Country:US
Practice Address - Phone:765-742-1567
Practice Address - Fax:765-742-2750
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71011419A363LP0200X
IN28224434A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse