Provider Demographics
NPI:1306079520
Name:MOTE, DEANNA DALE (NP-C)
Entity type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:DALE
Last Name:MOTE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8501 HARCOURT RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2046
Mailing Address - Country:US
Mailing Address - Phone:317-875-9105
Mailing Address - Fax:317-875-8638
Practice Address - Street 1:8501 HARCOURT RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2046
Practice Address - Country:US
Practice Address - Phone:317-875-9105
Practice Address - Fax:317-808-8802
Is Sole Proprietor?:No
Enumeration Date:2009-09-04
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003145A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201078070Medicaid
IN000000801153OtherANTHEM
IN062110K6Medicare PIN
IN815500016Medicare PIN