Basic Information
| Provider Information | |||||||||
| NPI: | 1134568108 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAVLINA | ||||||||
| FirstName: | JANNA | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | PEACOCK | ||||||||
| OtherFirstName: | JANNA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7424 SHADELAND STATION WAY | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462563925 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7591 TYLERS PLACE BLVD | ||||||||
| Address2: | |||||||||
| City: | WEST CHESTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450696308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137556600 | ||||||||
| FaxNumber: | 5137553762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2013 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 46002459A | IN | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SP11652 | OH | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 2187155 | 05 | OH | MEDICAID | AB7360731 | 01 | OH | MEDICARE PIN | OTHER |