Provider Demographics
NPI:1033782156
Name:DRAGONFLY PRIMARY CARE LLC
Entity Type:Organization
Organization Name:DRAGONFLY PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER., AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:WILES
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:317-501-8496
Mailing Address - Street 1:6835 E SOUTHPORT RD STE D
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-9714
Mailing Address - Country:US
Mailing Address - Phone:317-501-8496
Mailing Address - Fax:
Practice Address - Street 1:6835 E SOUTHPORT RD STE D
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-9714
Practice Address - Country:US
Practice Address - Phone:317-501-8496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty