Healthcare Provider Details

I. General information

NPI: 1093759102
Provider Name (Legal Business Name): DR. DEBORAH KINNAMON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 N SAMUEL MOORE PKWY STE C
MOORESVILLE IN
46158-1467
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-483-5080
  • Fax: 317-483-5085
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01052369
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01052369A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: