Provider Demographics
NPI:1912545021
Name:MORTLAND, DEVON LORAE
Entity Type:Individual
Prefix:
First Name:DEVON
Middle Name:LORAE
Last Name:MORTLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 W MCGALLIARD RD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-1774
Mailing Address - Country:US
Mailing Address - Phone:765-287-8460
Mailing Address - Fax:
Practice Address - Street 1:1313 W MCGALLIARD RD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-1774
Practice Address - Country:US
Practice Address - Phone:765-287-8460
Practice Address - Fax:765-287-8920
Is Sole Proprietor?:No
Enumeration Date:2019-12-19
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28233644A163WG0000X
IN71009894A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice