Healthcare Provider Details

I. General information

NPI: 1700877354
Provider Name (Legal Business Name): PEDIATRIC NURSING SPECIALISTS OF INDIANA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 DEPAUW BLVD SUITE 1041
INDIANAPOLIS IN
46268-1170
US

IV. Provider business mailing address

PO BOX 16809
HATTIESBURG MS
39404-6809
US

V. Phone/Fax

Practice location:
  • Phone: 317-875-6825
  • Fax: 317-802-2259
Mailing address:
  • Phone: 601-268-1842
  • Fax: 601-268-7898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MISS NANCY C JAKUS
Title or Position: VICE PRESIDENT OF OPERATIONS
Credential: RN BSN MBA
Phone: 601-268-1842