Healthcare Provider Details

I. General information

NPI: 1609176197
Provider Name (Legal Business Name): MEGAN MARIE CARLSON PNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2010
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 LAFAYETTE RD SUITE 200
INDIANAPOLIS IN
46222-1146
US

IV. Provider business mailing address

3400 LAFAYETTE RD SUITE 200
INDIANAPOLIS IN
46222-1146
US

V. Phone/Fax

Practice location:
  • Phone: 317-291-7422
  • Fax: 317-291-7433
Mailing address:
  • Phone: 317-291-7422
  • Fax: 317-291-7433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209.008391
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: