Healthcare Provider Details

I. General information

NPI: 1558442715
Provider Name (Legal Business Name): JESSICA M KANIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA M FANGMAN MD

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 RILEY DRIVE
INDIANAPOLIS IN
46202-5109
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-3936
  • Fax: 317-948-5844
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01072885A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.094922
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2083C0008X
TaxonomyClinical Informatics Physician
License Number01072885A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number01072885A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: