Healthcare Provider Details

I. General information

NPI: 1235705872
Provider Name (Legal Business Name): KELLY MCCOY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8414 NAAB RD
INDIANAPOLIS IN
46260-1972
US

IV. Provider business mailing address

8925 N MERIDIAN ST STE 200
INDIANAPOLIS IN
46260-2385
US

V. Phone/Fax

Practice location:
  • Phone: 317-338-7510
  • Fax: 317-338-7515
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number01095886A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberMT226575
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: