Provider Demographics
NPI:1538140348
Name:EVERLY, MARCEE
Entity Type:Individual
Prefix:
First Name:MARCEE
Middle Name:
Last Name:EVERLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 E RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-4744
Mailing Address - Country:US
Mailing Address - Phone:317-788-9769
Mailing Address - Fax:317-781-4868
Practice Address - Street 1:1633 N CAPITOL AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1261
Practice Address - Country:US
Practice Address - Phone:317-962-5014
Practice Address - Fax:317-962-2427
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN72000072A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200395860Medicaid
IN200395860Medicaid