Provider Demographics
NPI:1205940442
Name:TITCOMB, MARY EMILY (PNP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:EMILY
Last Name:TITCOMB
Suffix:
Gender:F
Credentials:PNP
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 11949
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46862-1949
Mailing Address - Country:US
Mailing Address - Phone:260-458-2641
Mailing Address - Fax:260-458-3093
Practice Address - Street 1:1717 S CALHOUN ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-5257
Practice Address - Country:US
Practice Address - Phone:260-458-2641
Practice Address - Fax:260-458-3093
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28116030A363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN84474-06OtherPNP