Provider Demographics
NPI:1518907344
Name:PETERSON-CLEMENT, GRETA P (NP)
Entity Type:Individual
Prefix:
First Name:GRETA
Middle Name:P
Last Name:PETERSON-CLEMENT
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
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 1:1633 N CAPITOL AVE
Practice Address - Street 2:STE 322
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1476
Practice Address - Country:US
Practice Address - Phone:317-962-2929
Practice Address - Fax:317-962-2070
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001060363L00000X
IN71001060A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200275780Medicaid
INQ53837Medicare UPIN
IN200275780Medicaid
IN264430118Medicare PIN
IN188920LMedicare PIN