Provider Demographics
NPI:1750632949
Name:BEDJA, SHANNON LEA (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LEA
Last Name:BEDJA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S PINE ST STE 120
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-2377
Mailing Address - Country:US
Mailing Address - Phone:812-524-3328
Mailing Address - Fax:812-524-3326
Practice Address - Street 1:225 S PINE ST STE 120
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2377
Practice Address - Country:US
Practice Address - Phone:812-524-3328
Practice Address - Fax:812-524-3326
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004158A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01588222OtherMEDICARE RAILROAD PTAN
IN266180605Medicare PIN