Provider Demographics
NPI:1992796619
Name:PEDIATRIC NURSING SPECIALISTS OF INDIANA, INC.
Entity type:Organization
Organization Name:PEDIATRIC NURSING SPECIALISTS OF INDIANA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:MISS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:C
Authorized Official - Last Name:JAKUS
Authorized Official - Suffix:
Authorized Official - Credentials:RN BSN MBA
Authorized Official - Phone:601-268-1842
Mailing Address - Street 1:PO BOX 16809
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-6809
Mailing Address - Country:US
Mailing Address - Phone:601-268-1842
Mailing Address - Fax:601-268-7898
Practice Address - Street 1:6523 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1551
Practice Address - Country:US
Practice Address - Phone:260-432-9699
Practice Address - Fax:260-432-5617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
157428Medicare ID - Type UnspecifiedPROVIDER NUMBER