Healthcare Provider Details

I. General information

NPI: 1336801539
Provider Name (Legal Business Name): MALLORY JANE BRAGG FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2021
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11876 OLIO RD STE 700
FISHERS IN
46037-9778
US

IV. Provider business mailing address

11876 OLIO RD STE 700
FISHERS IN
46037-9778
US

V. Phone/Fax

Practice location:
  • Phone: 317-348-3020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71011676A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: