Provider Demographics
NPI:1699263624
Name:BIGHEART, JOELYNN
Entity type:Individual
Prefix:
First Name:JOELYNN
Middle Name:
Last Name:BIGHEART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2787 EMERSON ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-3305
Mailing Address - Country:US
Mailing Address - Phone:219-512-8214
Mailing Address - Fax:
Practice Address - Street 1:2787 EMERSON ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-3305
Practice Address - Country:US
Practice Address - Phone:219-512-8214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27065113A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN51-0137391Medicaid