Healthcare Provider Details

I. General information

NPI: 1578234886
Provider Name (Legal Business Name): MRS. COURTNEY LEIGH WADSWORTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS COURTNEY LEIGH MALAN

II. Dates (important events)

Enumeration Date: 09/26/2021
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 RILEY HOSPITAL DR
INDIANAPOLIS IN
46202-5109
US

IV. Provider business mailing address

PO BOX 1026
INDIANAPOLIS IN
46206-1026
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-4846
  • Fax: 317-948-0126
Mailing address:
  • Phone: 317-777-6935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number28237991A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number71013024A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: