Provider Demographics
NPI:1104009430
Name:SIDHOM, SHAUNA KAY (NP)
Entity Type:Individual
Prefix:MRS
First Name:SHAUNA
Middle Name:KAY
Last Name:SIDHOM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:SHAUNA
Other - Middle Name:KAY
Other - Last Name:HOLLINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:200 SOUTH MERIDIAN STREET
Mailing Address - Street 2:SUITE 400
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4026 MADISON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227
Practice Address - Country:US
Practice Address - Phone:317-788-0396
Practice Address - Fax:317-780-0860
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002333A363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily