Provider Demographics
NPI:1417155656
Name:FAWCETT, KELLY N (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:N
Last Name:FAWCETT
Suffix:
Gender:F
Credentials:NP
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Other - Last Name:
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Mailing Address - Street 1:11595 N MERIDIAN ST
Mailing Address - Street 2:STE 375
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-3950
Mailing Address - Country:US
Mailing Address - Phone:317-575-7304
Mailing Address - Fax:317-575-7333
Practice Address - Street 1:10307 DUPONT CIRCLE DR W STE A
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1633
Practice Address - Country:US
Practice Address - Phone:260-458-3440
Practice Address - Fax:260-458-3441
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2021-11-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN71002401A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200867390Medicaid
IN259990EEMedicare PIN