Healthcare Provider Details

I. General information

NPI: 1992473755
Provider Name (Legal Business Name): MRS. JESSICA STOMBAUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2021
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 UNITY PL STE 145
LAFAYETTE IN
47905-5762
US

IV. Provider business mailing address

PO BOX 4699
LAFAYETTE IN
47903-4699
US

V. Phone/Fax

Practice location:
  • Phone: 765-446-5220
  • Fax: 765-446-5221
Mailing address:
  • Phone: 765-449-2732
  • Fax: 765-449-1196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28165476A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71012747A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: