Provider Demographics
NPI:1902503261
Name:MUDDASANI BHASYAM, PALLAVI REDDY (FNP)
Entity Type:Individual
Prefix:
First Name:PALLAVI REDDY
Middle Name:
Last Name:MUDDASANI BHASYAM
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 1:12286 WHISPERING BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-4452
Mailing Address - Country:US
Mailing Address - Phone:765-609-0506
Mailing Address - Fax:
Practice Address - Street 1:299 E PENDLETON AVE # 547
Practice Address - Street 2:
Practice Address - City:LAPEL
Practice Address - State:IN
Practice Address - Zip Code:46051-5546
Practice Address - Country:US
Practice Address - Phone:765-534-3636
Practice Address - Fax:765-534-3638
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71013615A363LF0000X
IN28254959A363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty