Healthcare Provider Details

I. General information

NPI: 1619415114
Provider Name (Legal Business Name): JENNY KNAPKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2017
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7333 W JEFFERSON BLVD
FORT WAYNE IN
46804-6280
US

IV. Provider business mailing address

830 W MAIN ST
COLDWATER OH
45828-1657
US

V. Phone/Fax

Practice location:
  • Phone: 260-458-3828
  • Fax:
Mailing address:
  • Phone: 567-890-7185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28201810A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: