Provider Demographics
NPI:1982061701
Name:NOTELLE, JONATHAN (ARNP)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:NOTELLE
Suffix:
Gender:M
Credentials:ARNP
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 670
Mailing Address - Street 2:
Mailing Address - City:HUNTERTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46748-0670
Mailing Address - Country:US
Mailing Address - Phone:260-748-3650
Mailing Address - Fax:260-748-3651
Practice Address - Street 1:1721 MAGNAVOX WAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1537
Practice Address - Country:US
Practice Address - Phone:260-748-3650
Practice Address - Fax:260-748-3651
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28202205A163W00000X
IN71006122A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1003883OtherBCBS
IN201350810Medicaid