Provider Demographics
NPI:1427613447
Name:POQUETTE, TIMOTHY (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:POQUETTE
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 HARTFORD ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2138
Mailing Address - Country:US
Mailing Address - Phone:765-742-1567
Mailing Address - Fax:765-742-2750
Practice Address - Street 1:1716 HARTFORD ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2138
Practice Address - Country:US
Practice Address - Phone:765-742-1567
Practice Address - Fax:765-742-2750
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009141A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300034486Medicaid