Provider Demographics
NPI:1619336096
Name:MOURICE, DINA M (AGNP-C)
Entity type:Individual
Prefix:
First Name:DINA
Middle Name:M
Last Name:MOURICE
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:DINA
Other - Middle Name:M
Other - Last Name:HERMINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5525 GEORGETOWN RD STE F
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-3717
Mailing Address - Country:US
Mailing Address - Phone:317-293-9039
Mailing Address - Fax:317-293-9049
Practice Address - Street 1:5525 GEORGETOWN RD STE F
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-3717
Practice Address - Country:US
Practice Address - Phone:317-293-9039
Practice Address - Fax:317-293-9049
Is Sole Proprietor?:No
Enumeration Date:2016-02-15
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006366A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01824438OtherRR PTAN