MEDICARE: MELISSA MATHIAS NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	71009541A	IN
2	363LP2300X	Primary Care Nurse Practitioner	71009541A	IN
3	363LA2200X	Adult Health Nurse Practitioner	71009541A	IN

General Provider Information

NPI Number	:	1235773995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA MATHIAS NP

Provider Business Mailing Address
First Line	:	8355 ROCKVILLE RD STE 120
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46234-2722
Country	:	US
Telephone Number	:	317-429-0061
Fax Number	:	317-222-1953

Provider Business Practice Location Address
First Line	:	8355 ROCKVILLE RD STE 120
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46234-2722
Country	:	US
Telephone Number	:	317-429-0061
Fax Number	:	317-222-1953

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/05/2019
Last Update Date	:	11/05/2019

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