Healthcare Provider Details

I. General information

NPI: 1740296581
Provider Name (Legal Business Name): LACEE MELEVAGE MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11725 N ILLINOIS ST SUITE 350
CARMEL IN
46032-3008
US

IV. Provider business mailing address

10330 N MERIDIAN ST SUITE 201
INDIANAPOLIS IN
46290-1024
US

V. Phone/Fax

Practice location:
  • Phone: 317-814-4547
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number71002226A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: