Provider Demographics
NPI:1063896934
Name:DALE, AMELIA B (PA-C)
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:B
Last Name:DALE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMELIA
Other - Middle Name:B
Other - Last Name:TURNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:RCS PROVIDER ENROLLMENT
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:765-254-4009
Mailing Address - Fax:
Practice Address - Street 1:2600 FERRY ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3055
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001854A363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN267030055Medicare PIN