Basic Information
| Provider Information | |||||||||
| NPI: | 1851675664 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSENBARK | ||||||||
| FirstName: | CHRISTI | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREGORY | ||||||||
| OtherFirstName: | CHRISTI | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 344 | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478420344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658281003 | ||||||||
| FaxNumber: | 7658281030 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 S MAIN ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CLINTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478422493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658281003 | ||||||||
| FaxNumber: | 7658281030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2011 | ||||||||
| LastUpdateDate: | 07/19/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71003729A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 201039780 | 05 | IN | MEDICAID |