MEDICARE: LAKEEA NEELY

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	261QV0200X	VA Clinic/Center
2	302R00000X	Health Maintenance Organization
3	311ZA0620X	Adult Care Home Facility	IN
4	347C00000X	Private Vehicle
5	343900000X	Non-emergency Medical Transport (VAN)	IN

General Provider Information

NPI Number	:	1801614482
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKEEA NEELY

Provider Business Mailing Address
First Line	:	3153 N PARK AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-3965
Country	:	US
Telephone Number	:	317-778-2707
Fax Number	:

Provider Business Practice Location Address
First Line	:	3153 N PARK AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-3965
Country	:	US
Telephone Number	:	317-778-2707
Fax Number	:

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

Provider Enumeration Date	:	10/01/2024
Last Update Date	:	10/01/2024

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Directions to “ LAKEEA NEELY ” Practice Location

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