Provider Demographics
NPI:1578689782
Name:LENFESTEY-DEMONT, JACQUELINE SUE (MSN, APRN, CNS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:SUE
Last Name:LENFESTEY-DEMONT
Suffix:
Gender:F
Credentials:MSN, APRN, CNS
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:LENFESTEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-3245
Mailing Address - Country:US
Mailing Address - Phone:574-647-1840
Mailing Address - Fax:
Practice Address - Street 1:1215 LAWN AVE
Practice Address - Street 2:STE 120
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2450
Practice Address - Country:US
Practice Address - Phone:574-523-2733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704255722363LF0000X
IN71002535A364SX0200X, 363LF0000X
IN70000200A364SX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SX0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200862570Medicaid
IN236040140OtherMEDICARE PTAN
IN261930019OtherMEDICARE PTAN
IN236040140OtherMEDICARE PTAN
IN000000514941OtherANTHEM BC&BS
MIN43780010Medicare PIN
IN000000944857OtherBCBS BMG CARDIOTHORACIC SURGERY
IN216950PMedicare PIN