Provider Demographics
NPI:1437454808
Name:HULL, SALLY ELIZABETH (NP)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:ELIZABETH
Last Name:HULL
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 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 NAVARRE PL STE 6600
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1173
Practice Address - Country:US
Practice Address - Phone:574-647-8800
Practice Address - Fax:574-647-8896
Is Sole Proprietor?:No
Enumeration Date:2011-01-17
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003539A363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201016390Medicaid
IN201016390Medicaid
IN000001019458OtherANTHEM BMG LAPORTE
INP01010045OtherRR MEDICARE
IN565800020Medicare PIN
INM400045856Medicare PIN