Provider Demographics
NPI:1255862223
Name:MERRELL, ABBY
Entity type:Individual
Prefix:
First Name:ABBY
Middle Name:
Last Name:MERRELL
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 1:3309 S 750 W
Mailing Address - Street 2:
Mailing Address - City:RUSSIAVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46979-9146
Mailing Address - Country:US
Mailing Address - Phone:765-883-2273
Mailing Address - Fax:
Practice Address - Street 1:3309 S 750 W
Practice Address - Street 2:
Practice Address - City:RUSSIAVILLE
Practice Address - State:IN
Practice Address - Zip Code:46979-9146
Practice Address - Country:US
Practice Address - Phone:765-883-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28223429A163W00000X
IN71007187A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001097050OtherANTHEM PROVIDER NUMEBR
IN300004634Medicaid
INPENDINGMedicare PIN