Provider Demographics
NPI:1124520069
Name:BOECKMAN, MANDY JEAN (FNP)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:JEAN
Last Name:BOECKMAN
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2796 W 500 S
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371-7308
Mailing Address - Country:US
Mailing Address - Phone:260-729-3523
Mailing Address - Fax:812-220-4280
Practice Address - Street 1:2796 W 500 S
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-7308
Practice Address - Country:US
Practice Address - Phone:260-729-3523
Practice Address - Fax:812-220-4280
Is Sole Proprietor?:No
Enumeration Date:2018-03-07
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007881A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN28209065AMedicaid