Provider Demographics
NPI:1508015439
Name:MANICKE, KELLY A (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:MANICKE
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:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7250 CLEARVISTA DR STE 355
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-5609
Practice Address - Country:US
Practice Address - Phone:317-621-5676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28164416163W00000X
IN71002746A363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000622179OtherANTHEM PROVIDER NUMBER
IN200920210Medicaid
INP00774860OtherRAILROAD MEDICARE
INP01678952OtherMEDICARE RAILROAD PTAN
IN247020PMedicare PIN
INP00774860OtherRAILROAD MEDICARE
IN149700011Medicare PIN
IN266180649Medicare PIN