Healthcare Provider Details

I. General information

NPI: 1104009430
Provider Name (Legal Business Name): SHAUNA KAY SIDHOM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHAUNA KAY HOLLINGER NP

II. Dates (important events)

Enumeration Date: 12/10/2007
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4026 MADISON AVE
INDIANAPOLIS IN
46227
US

IV. Provider business mailing address

200 SOUTH MERIDIAN STREET SUITE 400
INDIANAPOLIS IN
46225
US

V. Phone/Fax

Practice location:
  • Phone: 317-788-0396
  • Fax: 317-780-0860
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71002333A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71002333A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: