Provider Demographics
NPI:1750871687
Name:RIDDERHEIM, ELGERENE MONIQUE (NP)
Entity type:Individual
Prefix:
First Name:ELGERENE
Middle Name:MONIQUE
Last Name:RIDDERHEIM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ELGERENE
Other - Middle Name:MONIQUE
Other - Last Name:RIDDERHEIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:6729 EAST STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815
Mailing Address - Country:US
Mailing Address - Phone:260-492-0951
Mailing Address - Fax:
Practice Address - Street 1:6279 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-7641
Practice Address - Country:US
Practice Address - Phone:260-492-0951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008116A363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner