Provider Demographics
NPI:1730978644
Name:DOUGLAS, MARKEDA
Entity type:Individual
Prefix:
First Name:MARKEDA
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:
Credentials:
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 1986
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47996-1986
Mailing Address - Country:US
Mailing Address - Phone:765-409-7213
Mailing Address - Fax:
Practice Address - Street 1:1745 PAIGE RD APT 206
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909-3191
Practice Address - Country:US
Practice Address - Phone:765-409-7213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-06
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INHHA2401584374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide