Provider Demographics
NPI:1992733240
Name:SHICK, MARY SUSAN (MSN, ANP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:SHICK
Suffix:
Gender:F
Credentials:MSN, ANP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SUSAN
Other - Last Name:WATTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, ANP
Mailing Address - Street 1:421 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2403
Mailing Address - Country:US
Mailing Address - Phone:812-336-0168
Mailing Address - Fax:812-335-7372
Practice Address - Street 1:421 W 1ST ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2403
Practice Address - Country:US
Practice Address - Phone:812-336-0168
Practice Address - Fax:812-335-7372
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28090755A163WG0000X
IN71000080A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200076820AMedicaid
IN248430AMedicare PIN
IN200076820AMedicaid