Provider Demographics
NPI:1851854061
Name:PUELLO, BIANCA (MD)
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:
Last Name:PUELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BIANCA
Other - Middle Name:NICOLE PUELLO
Other - Last Name:YOCUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:350 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-4108
Mailing Address - Country:US
Mailing Address - Phone:317-274-2476
Mailing Address - Fax:
Practice Address - Street 1:350 W 11TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-4108
Practice Address - Country:US
Practice Address - Phone:317-274-2476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-13
Last Update Date:2019-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program