Healthcare Provider Details

I. General information

NPI: 1902068547
Provider Name (Legal Business Name): BETH A. THIELKING CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 W 10TH ST HS1001
INDIANAPOLIS IN
46202-3010
US

IV. Provider business mailing address

PO BOX 1026
INDIANAPOLIS IN
46206-1026
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-8812
  • Fax: 317-274-0133
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 Number28078636
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number71002369
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: