MEDICARE: FAMILY PRACTICE VISITING PROVIDERS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse

General Provider Information

NPI Number	:	1215439161
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY PRACTICE VISITING PROVIDERS LLC

Provider Business Mailing Address
First Line	:	120 EAST MARKET ST. SUITE 1273
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46204-3250
Country	:	US
Telephone Number	:	317-807-0859
Fax Number	:	317-807-0862

Provider Business Practice Location Address
First Line	:	120 E MARKET ST STE 1273
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46204-3250
Country	:	US
Telephone Number	:	317-807-0859
Fax Number	:	317-807-0862

Authorized Official
Title or Position	:	FAMILY NURSE PRACTITIONER
Name	:	MS. TAMMIE RENA MAIDEN
Credential	:	FNP
Telephone Number	:	937-248-9968

Provider Enumeration Date	:	03/07/2018
Last Update Date	:	03/07/2018

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