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General NPI Number Information
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NPI Number | 1457986259
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Entity Type | Individual
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Provider Name | WALTER ANDREW JAY MANDERY NP
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Gender | Male
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Dates
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Enumeration Date | 03/12/2020
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Last Update Date | 03/17/2023
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Provider Practice Location Address
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Address Line | 13345 ILLINOIS ST
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City | CARMEL
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State | IN
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Zip | 46032-3318
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Country | US
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Telephone | 317-396-1300
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Fax | 317-396-1346
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Provider Business Mailing Address
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Address Line | 13345 ILLINOIS ST
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City | CARMEL
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State | IN
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Zip | 46032-3318
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Country | US
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Telephone | 317-396-1300
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Fax | 317-396-1346
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 28199259A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 71009973A
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | 71009973A
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License Number State | IN
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