Healthcare Provider Details

I. General information

NPI: 1780932053
Provider Name (Legal Business Name): JANIS LORRAINE CHRISSIKOS RN, BSN, MSN, CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 11/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3732 NEW VISION DR
FORT WAYNE IN
46845-1703
US

IV. Provider business mailing address

1755 COUNTY ROAD 36
AUBURN IN
46706-9404
US

V. Phone/Fax

Practice location:
  • Phone: 260-373-1100
  • Fax: 260-373-1122
Mailing address:
  • Phone: 260-704-7166
  • Fax: 260-357-0282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number09000220A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number28120704A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: