Individual
JERI DINE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
ANP
Contact information
Practice address
1600 ALBANY ST, SOUTH ENTRANCE GROUND FLOOR, BEECH GROVE, IN 46107-1541
(317) 859-1090
(317) 859-3322
Mailing address
PO BOX 100, BEECH GROVE, IN 46107-0100
(317) 859-1090
(317) 859-3322
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
71000423A
IN
363LA2200X
Adult Health Nurse Practitioner
Primary
71000423A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000041022
M PLAN
IN
01
—
000000550394
ANTHEM
IN
01
—
0011953-21
NP CERTIFICATION
IN
01
—
11478722
CAQH
IN
05
—
200307870
—
IN
01
—
28065854A
RN LICENSE
IN
01
—
35-4994904
TID
IN
01
—
71000423B
CSR
IN
01
—
P00068634
RR MEDICARE
IN
Enumeration date
11/28/2007
Last updated
03/07/2023
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