1730448622 NPI number — KRYSTIN CHANELLE SHERIDAN ANP

Table of content: MICHAEL SEAN MADISON (NPI 1477812378)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730448622 NPI number — KRYSTIN CHANELLE SHERIDAN ANP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHERIDAN
Provider First Name:
KRYSTIN
Provider Middle Name:
CHANELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ANP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HUTCHISON
Provider Other First Name:
KRYSTIN
Provider Other Middle Name:
CHANELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ANP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730448622
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8433 HARCOURT RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46260-2193
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8433 HARCOURT RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-583-7600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/11/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  71003987A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 71003987A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 201077320 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".