Healthcare Provider Details

I. General information

NPI: 1205287075
Provider Name (Legal Business Name): JENNIFER CONDON WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 E HANNA AVE
INDIANAPOLIS IN
46227-1387
US

IV. Provider business mailing address

935 E HANNA AVE
INDIANAPOLIS IN
46227-1387
US

V. Phone/Fax

Practice location:
  • Phone: 317-803-4175
  • Fax:
Mailing address:
  • Phone: 317-788-0396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberCON104400820
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number28164436A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: