Healthcare Provider Details

I. General information

NPI: 1578056842
Provider Name (Legal Business Name): JENNA ELIZABETH BEDNARSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 06/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3741 ROME DR STE B
LAFAYETTE IN
47905-4490
US

IV. Provider business mailing address

3741 ROME DR STE B
LAFAYETTE IN
47905-4490
US

V. Phone/Fax

Practice location:
  • Phone: 765-607-6160
  • Fax: 765-607-6161
Mailing address:
  • Phone: 765-607-6160
  • Fax: 765-607-6161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number28228337A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: