Provider Demographics
NPI:1417086117
Name:AVITABILE, AUDREY C (ACNP-BC)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:C
Last Name:AVITABILE
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:C
Other - Last Name:KECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACNP-BC
Mailing Address - Street 1:1119 KEYSTONE WAY N.
Mailing Address - Street 2:SUITE 117
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-3356
Mailing Address - Country:US
Mailing Address - Phone:317-214-2100
Mailing Address - Fax:317-214-2101
Practice Address - Street 1:1119 KEYSTONE WAY N.
Practice Address - Street 2:SUITE 117
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032
Practice Address - Country:US
Practice Address - Phone:173-214-2100
Practice Address - Fax:317-214-2101
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71013514A363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71013514AOtherINDIANA BOARD OF NURSING
NCMK1609140OtherDEA NUMBER