Healthcare Provider Details

I. General information

NPI: 1790293843
Provider Name (Legal Business Name): KATELYN ROSE KIRKWOOD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATELYN ROSE WALKER

II. Dates (important events)

Enumeration Date: 01/10/2018
Last Update Date: 05/13/2023
Certification Date: 05/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8111 S EMERSON AVE STE 204
INDIANAPOLIS IN
46237-8601
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 317-528-2555
  • Fax: 317-528-2566
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002322A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: