Provider Demographics
NPI:1255542239
Name:O'CONNELL, MEGAN
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47901-1451
Mailing Address - Country:US
Mailing Address - Phone:765-423-2638
Mailing Address - Fax:765-742-4196
Practice Address - Street 1:610 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47901-1451
Practice Address - Country:US
Practice Address - Phone:765-423-2638
Practice Address - Fax:765-742-4196
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000173A364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health