Healthcare Provider Details

I. General information

NPI: 1851335251
Provider Name (Legal Business Name): KATHY G LIDDY NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 08/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 W 10TH ST
INDIANAPOLIS IN
46202-2803
US

IV. Provider business mailing address

8031 N COLLEGE AVE
INDIANAPOLIS IN
46240-2582
US

V. Phone/Fax

Practice location:
  • Phone: 317-554-0181
  • Fax: 317-554-0105
Mailing address:
  • Phone: 817-431-0542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number71000929A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number71000929A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71000929A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: