Healthcare Provider Details

I. General information

NPI: 1457718975
Provider Name (Legal Business Name): KELLY WHITE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2016
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8150 OAKLANDON RD STE 130
INDIANAPOLIS IN
46236-9554
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-1111
  • Fax: 317-621-1110
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number28160681A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number71006143A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: