Healthcare Provider Details

I. General information

NPI: 1134213168
Provider Name (Legal Business Name): JENNIFER R FRASURE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E CULVER RD STE 102
KNOX IN
46534-2241
US

IV. Provider business mailing address

PO BOX 1690
LA PORTE IN
46352-1690
US

V. Phone/Fax

Practice location:
  • Phone: 574-772-7918
  • Fax: 574-772-0894
Mailing address:
  • Phone: 219-326-2312
  • Fax: 219-326-2584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71001563
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: