Provider Demographics
NPI:1114296134
Name:SMITH, SUSAN C (ANP-BC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:SMITH
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E. 75TH STREET
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-4139
Mailing Address - Fax:317-621-7885
Practice Address - Street 1:8101 CLEARVISTA PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-4696
Practice Address - Country:US
Practice Address - Phone:317-621-5390
Practice Address - Fax:317-621-7885
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28093663A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201117920Medicaid
IN000000797592OtherBCBS
IN266180350Medicare PIN
IN719300003Medicare PIN