MEDICARE: PAMELA NUBONG

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	F12210302	IN
2	363L00000X	Nurse Practitioner	71012450A	IN

General Provider Information

NPI Number	:	1891436481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAMELA NUBONG

Provider Business Mailing Address
First Line	:	602 N HIGH SCHOOL RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46214-3694
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	602 N HIGH SCHOOL RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46214-3694
Country	:	US
Telephone Number	:	317-291-1211
Fax Number	:

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

Provider Enumeration Date	:	04/06/2022
Last Update Date	:	04/07/2022

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Directions to “ PAMELA NUBONG ” Practice Location

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