Basic Information
| Provider Information | |||||||||
| NPI: | 1023356656 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARINKOVICH-DAVIDSON | ||||||||
| FirstName: | JOANN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARINKOVICH | ||||||||
| OtherFirstName: | JOANN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8558 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193927084 | ||||||||
| FaxNumber: | 2197036854 | ||||||||
| Practice Location | |||||||||
| Address1: | 53880 CARMICHAEL DR | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466351567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742479441 | ||||||||
| FaxNumber: | 5742479442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2013 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 0000000000 | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 71004356A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.