Provider Demographics
NPI:1730840299
Name:AGBAZA, AUTUMN J (FNP-BC)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:J
Last Name:AGBAZA
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2238 LAMMERMOOR LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46214-2279
Mailing Address - Country:US
Mailing Address - Phone:317-437-6318
Mailing Address - Fax:
Practice Address - Street 1:6002 E 38TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-5614
Practice Address - Country:US
Practice Address - Phone:317-880-6002
Practice Address - Fax:317-880-0417
Is Sole Proprietor?:No
Enumeration Date:2022-01-06
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN21220818A163W00000X
IN71012160A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse