Healthcare Provider Details

I. General information

NPI: 1720797822
Provider Name (Legal Business Name): DESMOND A ATEM DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2022
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9105 E 56TH ST STE J
INDIANAPOLIS IN
46216-2231
US

IV. Provider business mailing address

9105 E 56TH ST STE J
INDIANAPOLIS IN
46216-2231
US

V. Phone/Fax

Practice location:
  • Phone: 260-508-6088
  • Fax: 260-344-8964
Mailing address:
  • Phone: 260-508-6088
  • Fax: 260-344-8964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61376005
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71013434A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number321417
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberC-RXN.0002570-C-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: