Healthcare Provider Details

I. General information

NPI: 1710396940
Provider Name (Legal Business Name): BERNITA FLYE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3919 W JEFFERSON BLVD
FORT WAYNE IN
46804-6811
US

IV. Provider business mailing address

6330 PINE MEADOWS LN
FORT WAYNE IN
46835-3800
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-7722
  • Fax:
Mailing address:
  • Phone: 260-486-3663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number28079791A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: