Healthcare Provider Details

I. General information

NPI: 1790140390
Provider Name (Legal Business Name): JEAN RENE MBASSI FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2015
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1522 W MORRIS ST
INDIANAPOLIS IN
46221-1629
US

IV. Provider business mailing address

3908 MEADOWS DR STE C
INDIANAPOLIS IN
46205-3114
US

V. Phone/Fax

Practice location:
  • Phone: 317-957-2500
  • Fax:
Mailing address:
  • Phone: 317-957-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02800
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71007963A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP-60600744
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: