Provider Demographics
NPI:1093690174
Name:GADDIS, MISCHA
Entity type:Individual
Prefix:
First Name:MISCHA
Middle Name:
Last Name:GADDIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2163 W 59TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46228-1719
Mailing Address - Country:US
Mailing Address - Phone:317-331-2924
Mailing Address - Fax:
Practice Address - Street 1:2163 W 59TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46228-1719
Practice Address - Country:US
Practice Address - Phone:317-331-2924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-07
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28231138C163WL0100X, 163WN1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163WN1003XNursing Service ProvidersRegistered NurseNutrition Support