Healthcare Provider Details

I. General information

NPI: 1477043495
Provider Name (Legal Business Name): KELLEY C SUMMERS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7250 CLEARVISTA DR STE 355
INDIANAPOLIS IN
46256
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-5676
  • Fax: 317-621-5678
Mailing address:
  • Phone: 317-621-7588
  • Fax: 317-957-2749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002484A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: