Healthcare Provider Details

I. General information

NPI: 1275969701
Provider Name (Legal Business Name): MINDY JO RUTAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2013
Last Update Date: 12/19/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8075 N SHADELAND AVE STE 350
INDIANAPOLIS IN
46250-2693
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-8668
  • Fax:
Mailing address:
  • Phone: 317-621-7547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF0613919
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71004656A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: