Healthcare Provider Details

I. General information

NPI: 1487204491
Provider Name (Legal Business Name): VANESSA LYNN NOVINGER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2019
Last Update Date: 06/11/2021
Certification Date: 06/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 W 16TH ST STE 5100
INDIANAPOLIS IN
46202-2274
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-963-1300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1168363
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002849A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: