Healthcare Provider Details

I. General information

NPI: 1003057951
Provider Name (Legal Business Name): KACY YEVONNE HEAD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KACY YEVONNE GRIFFIN PA-C

II. Dates (important events)

Enumeration Date: 03/23/2009
Last Update Date: 05/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL LN SUITE 105
DANVILLE IN
46122-1989
US

IV. Provider business mailing address

679 E COUNTY LINE RD
GREENWOOD IN
46143-1049
US

V. Phone/Fax

Practice location:
  • Phone: 317-745-3747
  • Fax: 317-745-3748
Mailing address:
  • Phone: 317-807-1262
  • Fax: 317-859-4268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA06217
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001167A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: