Healthcare Provider Details

I. General information

NPI: 1043911712
Provider Name (Legal Business Name): JENNIFER MICHELLE BATES MSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6211 WATERFORD BLVD
EVANSVILLE IN
47715-2869
US

IV. Provider business mailing address

6211 WATERFORD BLVD
EVANSVILLE IN
47715-2869
US

V. Phone/Fax

Practice location:
  • Phone: 812-456-6202
  • Fax: 618-997-8214
Mailing address:
  • Phone: 812-465-6202
  • Fax: 618-997-8214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: