Provider Demographics
NPI:1568834190
Name:HYDE, DESIRAE MASHELLE (NP)
Entity type:Individual
Prefix:
First Name:DESIRAE
Middle Name:MASHELLE
Last Name:HYDE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DESIRAE
Other - Middle Name:
Other - Last Name:THARPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1300 W JEFFERSON ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-9120
Mailing Address - Country:US
Mailing Address - Phone:317-736-8474
Mailing Address - Fax:317-736-6040
Practice Address - Street 1:1300 W JEFFERSON ST
Practice Address - Street 2:SUITE C
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-9120
Practice Address - Country:US
Practice Address - Phone:317-736-8474
Practice Address - Fax:317-736-6040
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005803A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ00551724OtherRAILROAD PTAN
IN201329340Medicaid
IN000001297549OtherATHEM PTAN
IN068010535OtherMEDICARE PTAN