Provider Demographics
NPI:1194068718
Name:DETWILER, JAMIE MARIE (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:MARIE
Last Name:DETWILER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 834
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46527-0834
Mailing Address - Country:US
Mailing Address - Phone:574-364-2611
Mailing Address - Fax:
Practice Address - Street 1:1852 ASHBURN DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6537
Practice Address - Country:US
Practice Address - Phone:574-533-5808
Practice Address - Fax:574-534-7215
Is Sole Proprietor?:No
Enumeration Date:2013-04-02
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004835A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily