Provider Demographics
NPI:1003058454
Name:DEAFENBAUGH, LUANN (NP)
Entity type:Individual
Prefix:
First Name:LUANN
Middle Name:
Last Name:DEAFENBAUGH
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:PO BOX 749495
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9495
Mailing Address - Country:US
Mailing Address - Phone:855-963-2100
Mailing Address - Fax:239-236-2775
Practice Address - Street 1:7910 W JEFFERSON BLVD STE 108
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4159
Practice Address - Country:US
Practice Address - Phone:260-436-0800
Practice Address - Fax:260-483-1911
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28067608363LF0000X
IN71002903A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200939080Medicare PIN
IN453220DDDMedicare PIN
IN262490HHMedicare PIN