Healthcare Provider Details

I. General information

NPI: 1427694983
Provider Name (Legal Business Name): SHEA ROBERT IDLEWINE FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2019
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2451 INTELLIPLEX DR STE 215
SHELBYVILLE IN
46176-8581
US

IV. Provider business mailing address

30 W RAMPART ST STE 200
SHELBYVILLE IN
46176-8846
US

V. Phone/Fax

Practice location:
  • Phone: 317-421-1917
  • Fax: 317-825-5303
Mailing address:
  • Phone: 317-421-2012
  • Fax: 317-398-1851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71009453A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: