Healthcare Provider Details

I. General information

NPI: 1508030891
Provider Name (Legal Business Name): MARY JEANNE DELISLE CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2008
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2732 W MICHIGAN ST
INDIANAPOLIS IN
46222-3750
US

IV. Provider business mailing address

2732 W MICHIGAN ST
INDIANAPOLIS IN
46222-3750
US

V. Phone/Fax

Practice location:
  • Phone: 317-554-4663
  • Fax:
Mailing address:
  • Phone: 317-554-4663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number70000062A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: