Healthcare Provider Details

I. General information

NPI: 1700430006
Provider Name (Legal Business Name): LUSINE VARDANYAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2019
Last Update Date: 08/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEMORIAL HOSPITAL AND HEALTH CARE CENTER 800 W 9TH STREET
JASPER IN
47546-2514
US

IV. Provider business mailing address

PO BOX 1028
JASPER IN
47547-1028
US

V. Phone/Fax

Practice location:
  • Phone: 812-996-6000
  • Fax: 812-996-0439
Mailing address:
  • Phone: 812-996-8478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71009254A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: