MEDICARE: PROVIDENCE WOUND CARE SPECIALISTS, 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	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1578426813
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE WOUND CARE SPECIALISTS, LLC

Provider Business Mailing Address
First Line	:	10917 GOSSAMER LN
Second Line	:
City	:	NOBLESVILLE
State	:	IN
Zip	:	46060-6106
Country	:	US
Telephone Number	:	317-365-6977
Fax Number	:	317-642-0687

Provider Business Practice Location Address
First Line	:	10917 GOSSAMER LN
Second Line	:
City	:	NOBLESVILLE
State	:	IN
Zip	:	46060-6106
Country	:	US
Telephone Number	:	317-365-6977
Fax Number	:	317-642-0687

Authorized Official
Title or Position	:	OWNER
Name	:	JAEKAR TEAH
Credential	:	NP
Telephone Number	:	317-701-5831

Provider Enumeration Date	:	12/04/2025
Last Update Date	:	01/12/2026

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