Healthcare Provider Details

I. General information

NPI: 1275863003
Provider Name (Legal Business Name): JEANINE SIROIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2009
Last Update Date: 12/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7509 CHARLESTOWN PIKE
CHARLESTOWN IN
47111-9623
US

IV. Provider business mailing address

2430 HIGHWAY 64 NW
RAMSEY IN
47166-8610
US

V. Phone/Fax

Practice location:
  • Phone: 812-256-4686
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number27061971A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: