MEDICARE: MOLLIE M ATHA 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	363LP0200X	Pediatric Nurse Practitioner	71014652A	IN
2	363LP0200X	Pediatric Nurse Practitioner	28251850A	IN
3	163W00000X	Registered Nurse	28251850A	IN

General Provider Information

NPI Number	:	1619697000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLIE M ATHA NP

Provider Business Mailing Address
First Line	:	3400 LAFAYETTE RD STE 200
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46222-1147
Country	:	US
Telephone Number	:	317-291-7422
Fax Number	:

Provider Business Practice Location Address
First Line	:	5801 E 30TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46218-3315
Country	:	US
Telephone Number	:	317-291-7422
Fax Number	:

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

Provider Enumeration Date	:	08/29/2022
Last Update Date	:	11/05/2025

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Directions to “ MOLLIE M ATHA NP” Practice Location

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