Provider Demographics
NPI:1043558596
Name:FOUTCH, KELLY L (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:FOUTCH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:KESSLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8607 E US HIGHWAY 36 STE 300
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-7960
Mailing Address - Country:US
Mailing Address - Phone:317-718-7960
Mailing Address - Fax:
Practice Address - Street 1:8607 E US HIGHWAY 36 STE 300
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7960
Practice Address - Country:US
Practice Address - Phone:317-718-7960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001285A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant