Provider Demographics
NPI:1205021268
Name:EVERETTE, KENYA (MD)
Entity Type:Individual
Prefix:DR
First Name:KENYA
Middle Name:
Last Name:EVERETTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3403 E RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-4744
Mailing Address - Country:US
Mailing Address - Phone:317-957-2000
Mailing Address - Fax:317-957-2050
Practice Address - Street 1:2855 N KEYSTONE AVE STE 100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46218-2790
Practice Address - Country:US
Practice Address - Phone:317-957-2300
Practice Address - Fax:317-957-2320
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080824207Q00000X
IL036107482207Q00000X
IN01050551A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200291750Medicaid
IN000000745899OtherANTHEM TRADITIONAL
IN000000745899OtherANTHEM TRADITIONAL