MEDICARE: JANIS LORRAINE CHRISSIKOS RN, BSN, MSN, CNM

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	163WM0102X	Maternal Newborn Registered Nurse	28120704A	IN
2	367A00000X	Advanced Practice Midwife	09000220A	IN

General Provider Information

NPI Number	:	1780932053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANIS LORRAINE CHRISSIKOS RN, BSN, MSN, CNM

Provider Business Mailing Address
First Line	:	1755 COUNTY ROAD 36
Second Line	:
City	:	AUBURN
State	:	IN
Zip	:	46706-9404
Country	:	US
Telephone Number	:	260-704-7166
Fax Number	:	260-357-0282

Provider Business Practice Location Address
First Line	:	3732 NEW VISION DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1703
Country	:	US
Telephone Number	:	260-373-1100
Fax Number	:	260-373-1122

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2012
Last Update Date	:	11/28/2013

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