Provider Demographics
NPI:1952499956
Name:SEIBOLD, BRENDA E (FNP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:E
Last Name:SEIBOLD
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:PO BOX 389
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47842-0389
Mailing Address - Country:US
Mailing Address - Phone:765-505-5200
Mailing Address - Fax:765-505-5202
Practice Address - Street 1:324 BLACKMAN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IN
Practice Address - Zip Code:47842-2309
Practice Address - Country:US
Practice Address - Phone:765-505-5200
Practice Address - Fax:765-505-5202
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001944B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200805370Medicaid
INP81128Medicare UPIN
IN200805370Medicaid