Healthcare Provider Details

I. General information

NPI: 1831961077
Provider Name (Legal Business Name): GINGER BAKER TANKOVICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 10/23/2023
Certification Date: 10/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8111 TOWNSHIP LINE RD
INDIANAPOLIS IN
46260-2479
US

IV. Provider business mailing address

8111 TOWNSHIP LINE RD
INDIANAPOLIS IN
46260-2479
US

V. Phone/Fax

Practice location:
  • Phone: 317-415-7441
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number28270070A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: