Healthcare Provider Details

I. General information

NPI: 1093493371
Provider Name (Legal Business Name): THAO T MERRELL CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2023
Last Update Date: 04/14/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 RILEY HOSPITAL DR
INDIANAPOLIS IN
46202-5109
US

IV. Provider business mailing address

PO BOX 778912
CHICAGO IL
60677-8912
US

V. Phone/Fax

Practice location:
  • Phone: 317-948-7208
  • Fax: 317-944-5791
Mailing address:
  • Phone: 317-777-6435
  • Fax: 317-777-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number28241711A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number71013931A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: