Basic Information
| Provider Information | |||||||||
| NPI: | 1336513373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARMER | ||||||||
| FirstName: | DWIGHT | ||||||||
| MiddleName: | MONTEAL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | REGISTERED NURSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 622 E 54TH PL | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464101623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193815246 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 901 MACARTHUR BLVD | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463212901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198361600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2015 | ||||||||
| LastUpdateDate: | 11/13/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 28176200A | IN | Y | Nursing Service Providers | Registered Nurse |
No ID Information.