Provider Demographics
NPI:1457343436
Name:RADEMAKER, ANN E (NP)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:E
Last Name:RADEMAKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:E
Other - Last Name:TINKLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11108 PARKVIEW CIRCLE DR
Practice Address - Street 2:ATTENTION: POLLY BALOSKI
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1730
Practice Address - Country:US
Practice Address - Phone:260-266-5700
Practice Address - Fax:260-266-5920
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001857A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000641096OtherANTHEM
IN200507030Medicaid
INP00825411OtherR.R. MEDICARE
IN193590AAMedicare PIN
IN200507030Medicaid
IN264380TMedicare UPIN