Provider Demographics
NPI:1174073373
Name:HARLESS, ANNE G W (NP)
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:G W
Last Name:HARLESS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:IN
Mailing Address - Zip Code:46064-1232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3512 STELLHORN RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4631
Practice Address - Country:US
Practice Address - Phone:260-483-9081
Practice Address - Fax:260-483-9196
Is Sole Proprietor?:No
Enumeration Date:2016-10-12
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006721A364SA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201405200Medicaid
INP01751331OtherRR MEDICARE
IN266180864Medicare PIN