Provider Demographics
NPI:1467516500
Name:PATTISON, SHELLEY R (NP)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:R
Last Name:PATTISON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
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 1:1801 N. SENATE BLVD
Practice Address - Street 2:SUITE 310
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1252
Practice Address - Country:US
Practice Address - Phone:317-962-2500
Practice Address - Fax:317-962-2515
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71002295A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200851490Medicaid
IN200851490Medicaid
INM400015078Medicare PIN
INM400072036Medicare PIN