Healthcare Provider Details

I. General information

NPI: 1295147171
Provider Name (Legal Business Name): MILDRED ZINZOMBE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2014
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 W 86TH ST
INDIANAPOLIS IN
46260-2101
US

IV. Provider business mailing address

1375 W 86TH ST
INDIANAPOLIS IN
46260-2101
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28189734A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: