Provider Demographics
NPI:1144736398
Name:SHULTZ, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:SHULTZ
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 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-497-1900
Mailing Address - Fax:317-497-1919
Practice Address - Street 1:8920 SOUTHPOINTE DR STE B
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227
Practice Address - Country:US
Practice Address - Phone:317-497-1900
Practice Address - Fax:317-497-1919
Is Sole Proprietor?:No
Enumeration Date:2017-12-26
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28169780A363LF0000X
IN71007710A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300028901Medicaid