Healthcare Provider Details

I. General information

NPI: 1336181973
Provider Name (Legal Business Name): JENNIFER RENEE PRUZIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 01/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 MACARTHUR BLVD SUITE 401
MUNSTER IN
46321-2915
US

IV. Provider business mailing address

10318 FOX RUN
MUNSTER IN
46321-4337
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-7713
  • Fax: 219-836-7083
Mailing address:
  • Phone: 219-924-1399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71001168A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: