Healthcare Provider Details

I. General information

NPI: 1851663264
Provider Name (Legal Business Name): MARY REARDON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2012
Last Update Date: 01/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 W 10TH ST
INDIANAPOLIS IN
46202-2803
US

IV. Provider business mailing address

5722 CASTLE HILL DR # 612
INDIANAPOLIS IN
46250-5602
US

V. Phone/Fax

Practice location:
  • Phone: 317-554-0000
  • Fax:
Mailing address:
  • Phone: 317-363-0251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number28097017A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: