Provider Demographics
NPI:1508399379
Name:REARDON, ABIGAIL (FNP)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
Last Name:REARDON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15900 W 101ST AVE
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-3065
Mailing Address - Country:US
Mailing Address - Phone:219-365-6333
Mailing Address - Fax:219-365-8291
Practice Address - Street 1:15900 W 101ST AVE
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-3065
Practice Address - Country:US
Practice Address - Phone:219-365-6333
Practice Address - Fax:219-365-8291
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006992A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200760Medicare PIN