Healthcare Provider Details

I. General information

NPI: 1730579525
Provider Name (Legal Business Name): DIANE LYNN BRACKIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANE LYNN SMITH NP

II. Dates (important events)

Enumeration Date: 01/31/2015
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9894 E 121ST ST
FISHERS IN
46037-4154
US

IV. Provider business mailing address

6626 E 75TH ST SUITE 500
INDIANAPOLIS IN
46250-2805
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-4900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number71005606A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number28124384A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: