Provider Demographics
NPI:1083492532
Name:SMALLWOOD, AUDRA MARIE (NP)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:MARIE
Last Name:SMALLWOOD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AUDRA
Other - Middle Name:MARIE
Other - Last Name:HEDRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1801 N SENATE BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-1228
Mailing Address - Country:US
Mailing Address - Phone:317-962-0582
Mailing Address - Fax:
Practice Address - Street 1:720 ESKENAZI AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5187
Practice Address - Country:US
Practice Address - Phone:317-880-7666
Practice Address - Fax:317-880-0448
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28244569A163W00000X
IN71014396A363LC0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine