Provider Demographics
NPI:1225359193
Name:BUSSARD, KATIE M (NP)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:M
Last Name:BUSSARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:M
Other - Last Name:ACTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-962-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-15
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28150966A163W00000X
IN71003317A363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN264430F53OtherMEDICARE PTAN
IN267030053OtherMEDICARE PTAN
IN201098700Medicaid