Healthcare Provider Details

I. General information

NPI: 1043588908
Provider Name (Legal Business Name): MICHELLE DIANE MCKINNEY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2011
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7212 US 31 S
INDIANAPOLIS IN
46227-8549
US

IV. Provider business mailing address

7148 BEL MOORE CIR
INDIANAPOLIS IN
46259-9666
US

V. Phone/Fax

Practice location:
  • Phone: 317-889-9822
  • Fax: 317-889-6500
Mailing address:
  • Phone: 317-750-8792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05006844A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: