Provider Demographics
NPI:1467429068
Name:BANEY, JILL A (NP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:A
Last Name:BANEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:MEDPARTNERS, ATTN: BARB COPELAND
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3514
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:7916 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-432-2297
Practice Address - Fax:260-434-6433
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2016-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000588A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2454320Medicaid
500016208OtherRAILROAD
IN200321220Medicaid
IN000000289311OtherANTHEM
INS78616Medicare UPIN
IN200321220Medicaid
IN260690KMedicare PIN
IN200321220Medicaid
IN260690KMedicare PIN