Healthcare Provider Details

I. General information

NPI: 1851108773
Provider Name (Legal Business Name): EVANN RAE ROSEBROUGH CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2024
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8111 TOWNSHIP LINE RD
INDIANAPOLIS IN
46260-2479
US

IV. Provider business mailing address

7249 RED MAPLE DR
ZIONSVILLE IN
46077-7759
US

V. Phone/Fax

Practice location:
  • Phone: 317-415-8111
  • Fax:
Mailing address:
  • Phone: 317-503-6766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: