Healthcare Provider Details

I. General information

NPI: 1972273118
Provider Name (Legal Business Name): KRISTEN ELY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN FREEMAN

II. Dates (important events)

Enumeration Date: 09/19/2021
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
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: 317-948-7128
  • Fax:
Mailing address:
  • Phone: 317-777-6435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number28205452A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: