Individual
BLAKE ALAN LUEBBEHUSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MSN, RN, NP-C
Contact information
Practice address
500 ARCADE AVE STE 210, ELKHART, IN 46514-2485
(574) 389-5656
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
71010668A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
236040357
MEDICARE PTAN
IN
05
—
300045960
—
IN
Enumeration date
11/23/2020
Last updated
03/30/2021
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