Provider Demographics
NPI:1487047965
Name:DOUGLAS, BOBBIE (NP)
Entity type:Individual
Prefix:
First Name:BOBBIE
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3125 S SCATTERFIELD RD STE 300
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46013-1803
Practice Address - Country:US
Practice Address - Phone:765-298-4311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-09
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005471A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201289090Medicaid
INP01512390OtherRR MEDICARE
IN71005471AOtherINDIANA APN LICENSE
IN28142824AOtherRN IN LICENSE
IN201289090Medicaid