Healthcare Provider Details

I. General information

NPI: 1396172268
Provider Name (Legal Business Name): SHERRY BOWEN-BUZARD NP SOUTHSIDE PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2013
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8686 MADISON AVE SUITE F
INDIANAPOLIS IN
46227-7207
US

IV. Provider business mailing address

8686 MADISON AVE SUITE F
INDIANAPOLIS IN
46227-7207
US

V. Phone/Fax

Practice location:
  • Phone: 317-353-3811
  • Fax: 317-454-1397
Mailing address:
  • Phone: 317-353-3811
  • Fax: 317-454-1397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number71002414A
License Number StateIN

VIII. Authorized Official

Name: GIANNA LYNN
Title or Position: OFFICE MANAGER
Credential:
Phone: 317-353-3811