Healthcare Provider Details

I. General information

NPI: 1992394126
Provider Name (Legal Business Name): CODY KNECHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 PEARL ST
COVINGTON IN
47932-1455
US

IV. Provider business mailing address

828 PEARL ST
COVINGTON IN
47932-1455
US

V. Phone/Fax

Practice location:
  • Phone: 765-585-4296
  • Fax:
Mailing address:
  • Phone: 765-585-4296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0100X
TaxonomyGastroenterology Registered Nurse
License Number28253548A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: