Provider Demographics
NPI:1538250618
Name:DEFABIS, THERESE LYNN (APRN, ANP-BC)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:LYNN
Last Name:DEFABIS
Suffix:
Gender:F
Credentials:APRN, ANP-BC
Other - Prefix:
Other - First Name:THERESE
Other - Middle Name:LYNN
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 211699
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-3699
Mailing Address - Country:US
Mailing Address - Phone:866-849-0692
Mailing Address - Fax:888-973-8821
Practice Address - Street 1:155 E MARKET ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-3294
Practice Address - Country:US
Practice Address - Phone:866-849-0692
Practice Address - Fax:888-973-8821
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11037167363L00000X
COC-APN.0103422-C-NP363LA2200X
OH0038109363LA2200X
IN71000314A363LA2200X
IN71000314363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200855440Medicaid
INR78150Medicare UPIN
P00385034Medicare PIN
IN152410TTMedicare PIN
IN200855440Medicaid