Healthcare Provider Details

I. General information

NPI: 1770851610
Provider Name (Legal Business Name): LEO SHANNON O'CONNOR NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2011
Last Update Date: 01/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11455 N MERIDIAN ST 200
CARMEL IN
46032-1624
US

IV. Provider business mailing address

12302 HANCOCK ST
CARMEL IN
46032-5807
US

V. Phone/Fax

Practice location:
  • Phone: 317-582-8180
  • Fax: 317-582-8182
Mailing address:
  • Phone: 317-564-4836
  • Fax: 317-587-2341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number28129315A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: