Healthcare Provider Details

I. General information

NPI: 1669019717
Provider Name (Legal Business Name): JENNIFER ANN GROSSI NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER ANN MADDOX

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 RILEY HOSPITAL DR RI 1134
INDIANAPOLIS IN
46202-5109
US

IV. Provider business mailing address

PO BOX 1026
INDIANAPOLIS IN
46206-1026
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-8906
  • Fax: 317-944-9330
Mailing address:
  • Phone: 317-777-6435
  • Fax: 317-777-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number71003801
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: