Provider Demographics
NPI:1396938429
Name:FUNK, DIANE ELAINE (NP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:ELAINE
Last Name:FUNK
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 1:6100 W 96TH ST
Mailing Address - Street 2:SUITE 125
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-6005
Mailing Address - Country:US
Mailing Address - Phone:317-715-1800
Mailing Address - Fax:317-715-6200
Practice Address - Street 1:8301 HARCOURT RD
Practice Address - Street 2:RADIATION ONCOLOGY DEPT, STE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2081
Practice Address - Country:US
Practice Address - Phone:317-415-6783
Practice Address - Fax:317-415-6758
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001509A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000864920OtherANTHEM
IN201216930Medicaid
IN71001509BOtherAPN CSR
INMH0926949OtherDEA
INMH0926949OtherDEA