Healthcare Provider Details

I. General information

NPI: 1487813085
Provider Name (Legal Business Name): PENELOPE FAY CALLAWAY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 E NATIONAL AVE STE 100
BRAZIL IN
47834-2700
US

IV. Provider business mailing address

1214 E NATIONAL AVE STE 100
BRAZIL IN
47834-2700
US

V. Phone/Fax

Practice location:
  • Phone: 812-442-2100
  • Fax:
Mailing address:
  • Phone: 812-442-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71002646A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: