Healthcare Provider Details

I. General information

NPI: 1104211416
Provider Name (Legal Business Name): REGINA SHEA DALLA RIVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6940 MICHIGAN RD STE 140
INDIANAPOLIS IN
46268-2800
US

IV. Provider business mailing address

PO BOX 637764
CINCINNATI OH
45263-7764
US

V. Phone/Fax

Practice location:
  • Phone: 317-266-2901
  • Fax:
Mailing address:
  • Phone: 317-880-3939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number66402-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: