Provider Demographics
NPI:1295200574
Name:KELLY, MEREDITH SUSANNE
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:SUSANNE
Last Name:KELLY
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 1:8954 GLASS CHIMNEY LN
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-9438
Mailing Address - Country:US
Mailing Address - Phone:317-501-0641
Mailing Address - Fax:
Practice Address - Street 1:5256 E 65TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-4819
Practice Address - Country:US
Practice Address - Phone:317-429-0120
Practice Address - Fax:866-202-5499
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008472A363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily