Healthcare Provider Details

I. General information

NPI: 1740579929
Provider Name (Legal Business Name): LAUREN NICOLE BRANKLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2011
Last Update Date: 02/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 W 86TH ST
INDIANAPOLIS IN
46260-1902
US

IV. Provider business mailing address

250 W 96TH ST # 520
INDIANAPOLIS IN
46260-1316
US

V. Phone/Fax

Practice location:
  • Phone: 317-338-8861
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number02004452A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: