Healthcare Provider Details

I. General information

NPI: 1619697000
Provider Name (Legal Business Name): MOLLIE M ATHA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 E 30TH ST
INDIANAPOLIS IN
46218-3315
US

IV. Provider business mailing address

3400 LAFAYETTE RD STE 200
INDIANAPOLIS IN
46222-1147
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number71014652A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number28251850A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28251850A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: