Healthcare Provider Details

I. General information

NPI: 1982269544
Provider Name (Legal Business Name): KATIE R GUNTLE RRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATIE BAVENDER RRA

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 12/29/2020
Certification Date: 12/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9998 CROSSPOINT BLVD STE 200
INDIANAPOLIS IN
46256-3307
US

IV. Provider business mailing address

9998 CROSSPOINT BLVD STE 200
INDIANAPOLIS IN
46256-3307
US

V. Phone/Fax

Practice location:
  • Phone: 317-579-2150
  • Fax: 317-579-2130
Mailing address:
  • Phone: 317-579-2150
  • Fax: 317-579-2130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License NumberXT022920
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: