Provider Demographics
NPI:1073375218
Name:STUART, KATHLEEN THEISEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:THEISEN
Last Name:STUART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:LUCILLE
Other - Last Name:THEISEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 RED OAK LN
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-1807
Mailing Address - Country:US
Mailing Address - Phone:317-716-9131
Mailing Address - Fax:
Practice Address - Street 1:8111 TOWNSHIP LINE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2479
Practice Address - Country:US
Practice Address - Phone:317-415-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28224547C163WN0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care