Healthcare Provider Details

I. General information

NPI: 1720039589
Provider Name (Legal Business Name): JEAN M BANDOS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W 10TH ST
INDIANAPOLIS IN
46202-2859
US

IV. Provider business mailing address

PO BOX 78158
INDIANAPOLIS IN
46278-0158
US

V. Phone/Fax

Practice location:
  • Phone: 317-808-0573
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number70000182A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: