Healthcare Provider Details

I. General information

NPI: 1033519301
Provider Name (Legal Business Name): CONNIE PUMPELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2014
Last Update Date: 08/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12092 N PADDOCK RD
CAMBY IN
46113-8549
US

IV. Provider business mailing address

12092 N PADDOCK RD
CAMBY IN
46113-8549
US

V. Phone/Fax

Practice location:
  • Phone: 317-831-9781
  • Fax:
Mailing address:
  • Phone: 317-831-9781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000621A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: