Basic Information
| Provider Information | |||||||||
| NPI: | 1083867089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLAUGHRY | ||||||||
| FirstName: | BRANDY | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN, ANP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RENZ | ||||||||
| OtherFirstName: | BRANDY | ||||||||
| OtherMiddleName: | JO | ||||||||
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| OtherCredential: | RN, ANP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | STE 130 PROVIDER ENROLLMENT | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2401 W UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609691950 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2008 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71002848A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | 71002848A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 163W00000X | 28157189A | IN | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 000000626639 | 01 | IN | ANTHEM BC/BS | OTHER | P00719994 | 01 | IN | RAILROAD MEDICARE | OTHER | 200935360 | 05 | IN | MEDICAID | 000000609123 | 01 | IN | ANTHEM BC/BS | OTHER | 000000659985 | 01 | IN | ANTHEM BC/BS | OTHER | P00742234 | 01 | IN | RAILROAD MEDICARE | OTHER |