Provider Demographics
NPI:1871014589
Name:HARRIS, MINDY (FNP)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15133 LIONS PSGE
Mailing Address - Street 2:
Mailing Address - City:LEO
Mailing Address - State:IN
Mailing Address - Zip Code:46765-9597
Mailing Address - Country:US
Mailing Address - Phone:260-341-2397
Mailing Address - Fax:
Practice Address - Street 1:11143 PARKVIEW PLAZA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1727
Practice Address - Country:US
Practice Address - Phone:260-425-6330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-03
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007377A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1871523787Medicaid