Provider Demographics
NPI:1336410703
Name:CAIN, RICHARD LAMAR (NP)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LAMAR
Last Name:CAIN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:
Other - Last Name:CAIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMNHP-BC
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3512 STELLHORN RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4631
Practice Address - Country:US
Practice Address - Phone:260-483-9081
Practice Address - Fax:260-483-9196
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28173909A163WP0809X
IN71004523B363LP0808X
IN71004523A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN224350035OtherMEDICARE
IN201187370Medicaid