Provider Demographics
NPI:1366624728
Name:DINE, JERI (ANP)
Entity type:Individual
Prefix:
First Name:JERI
Middle Name:
Last Name:DINE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:JERI
Other - Middle Name:
Other - Last Name:GALLOWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:BEECH GROVE
Mailing Address - State:IN
Mailing Address - Zip Code:46107-0100
Mailing Address - Country:US
Mailing Address - Phone:317-859-1090
Mailing Address - Fax:317-859-3322
Practice Address - Street 1:1600 ALBANY ST
Practice Address - Street 2:SOUTH ENTRANCE GROUND FLOOR
Practice Address - City:BEECH GROVE
Practice Address - State:IN
Practice Address - Zip Code:46107-1541
Practice Address - Country:US
Practice Address - Phone:317-859-1090
Practice Address - Fax:317-859-3322
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000423A363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0011953-21OtherNP CERTIFICATION
IN000000041022OtherM PLAN
IN35-4994904OtherTID
INP00068634OtherRR MEDICARE
IN11478722OtherCAQH
IN28065854AOtherRN LICENSE
IN71000423BOtherCSR
IN000000550394OtherANTHEM
IN200307870Medicaid
IN200307870Medicaid
IN200307870Medicaid
IN899970AMedicare PIN