Provider Demographics
NPI:1629647615
Name:RICHARDSON, JANETTE (MSN, RN, AGCNS-BC)
Entity Type:Individual
Prefix:MRS
First Name:JANETTE
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MSN, RN, AGCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11104 PARKVIEW CIRCLE DR STE 410
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-0025
Practice Address - Country:US
Practice Address - Phone:260-266-7856
Practice Address - Fax:260-266-5279
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71012028A363L00000X, 364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN28182737AOtherRN INDIANA NURSING LICENSE