Basic Information
| Provider Information | |||||||||
| NPI: | 1821594672 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASTRO | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRUNSMAN | ||||||||
| OtherFirstName: | JEAN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176219312 | ||||||||
| FaxNumber: | 3176216920 | ||||||||
| Practice Location | |||||||||
| Address1: | 1251 HUNTZINGER BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | PENDLETON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652984567 | ||||||||
| FaxNumber: | 7652984568 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2018 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 28209389A | IN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 71008245A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.