Provider Demographics
NPI:1932860632
Name:AMANDA REGESTER PEDIATRIC HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:AMANDA REGESTER PEDIATRIC HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE-MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:REGESTER
Authorized Official - Suffix:
Authorized Official - Credentials:PNP
Authorized Official - Phone:317-450-8498
Mailing Address - Street 1:1535 S ANDREW CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-7147
Mailing Address - Country:US
Mailing Address - Phone:317-450-8498
Mailing Address - Fax:
Practice Address - Street 1:654 S WALKER ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2159
Practice Address - Country:US
Practice Address - Phone:812-369-4344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-04
Last Update Date:2022-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty