Healthcare Provider Details

I. General information

NPI: 1457177503
Provider Name (Legal Business Name): KELSEY LYNNE GRENNELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2024
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E 34TH ST
INDIANAPOLIS IN
46205-3754
US

IV. Provider business mailing address

1909 31ST AVE SW APT 465
MINOT ND
58701-7464
US

V. Phone/Fax

Practice location:
  • Phone: 317-926-1507
  • Fax:
Mailing address:
  • Phone: 517-896-4640
  • Fax: 701-377-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAC1121
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: