Healthcare Provider Details

I. General information

NPI: 1538048376
Provider Name (Legal Business Name): KELLY R DOMENECH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2025
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 W 16TH ST STE 2800
INDIANAPOLIS IN
46202-2279
US

IV. Provider business mailing address

355 W 16TH ST STE 2800
INDIANAPOLIS IN
46202-2279
US

V. Phone/Fax

Practice location:
  • Phone: 317-963-7300
  • Fax: 317-963-7075
Mailing address:
  • Phone: 317-963-7300
  • Fax: 317-963-7075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71017023A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71017023A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: