Provider Demographics
NPI:1174616791
Name:MUMMERT, ANNE L (OTR)
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:L
Last Name:MUMMERT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-449-2732
Mailing Address - Fax:765-449-1196
Practice Address - Street 1:917 SAGAMORE PKWY W
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1443
Practice Address - Country:US
Practice Address - Phone:765-463-2200
Practice Address - Fax:765-463-3625
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31001067A225X00000X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000758022OtherANTHEM PIN - IU HEALTH ARNETT
IN200036740Medicaid
INP01101231Medicare PIN
IN062110I8Medicare PIN
IN000000758022OtherANTHEM PIN - IU HEALTH ARNETT
INM400068109Medicare PIN
INP00702362Medicare PIN