Healthcare Provider Details

I. General information

NPI: 1467429068
Provider Name (Legal Business Name): JILL A. BANEY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 12/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7916 W JEFFERSON BLVD
FORT WAYNE IN
46804-4140
US

IV. Provider business mailing address

6920 POINTE INVERNESS WAY STE 200 MEDPARTNERS, ATTN: BARB COPELAND
FORT WAYNE IN
46804-7934
US

V. Phone/Fax

Practice location:
  • Phone: 260-432-2297
  • Fax: 260-434-6433
Mailing address:
  • Phone: 260-479-3514
  • Fax: 260-479-3520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71000588A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: