Healthcare Provider Details

I. General information

NPI: 1033879168
Provider Name (Legal Business Name): MELISSA ANN REVARD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2021
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 W 86TH ST
INDIANAPOLIS IN
46260-1902
US

IV. Provider business mailing address

2001 W 86TH ST
INDIANAPOLIS IN
46260-1902
US

V. Phone/Fax

Practice location:
  • Phone: 317-338-6815
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number28201775A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71012244A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number263216
License Number StateMT
# 4
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number71012244A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: