Provider Demographics
NPI:1235357864
Name:SPIVEY, SUZAN DENISE (NP)
Entity Type:Individual
Prefix:MRS
First Name:SUZAN
Middle Name:DENISE
Last Name:SPIVEY
Suffix:
Gender:F
Credentials:NP
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
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N RITTER AVE
Practice Address - Street 2:STE 520
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3052
Practice Address - Country:US
Practice Address - Phone:317-355-1234
Practice Address - Fax:317-355-1505
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000878A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71000878AOtherSTATE LICENSE NUMBER
IN200280400Medicaid
INP01209645OtherRR MEDICARE PTAN
INP01209645OtherRR MEDICARE PTAN
MS0570386OtherDEA NUMBER
INP35163Medicare UPIN