Healthcare Provider Details

I. General information

NPI: 1366319469
Provider Name (Legal Business Name): LATEASA TYLER NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2025
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 MEDICAL DR
CARMEL IN
46032-3323
US

IV. Provider business mailing address

11313 USA PKWY STE E148
FISHERS IN
46037-9208
US

V. Phone/Fax

Practice location:
  • Phone: 317-844-4211
  • Fax:
Mailing address:
  • Phone: 317-781-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number28196273A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: