Provider Demographics
NPI:1578234886
Name:WADSWORTH, COURTNEY LEIGH
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:LEIGH
Last Name:WADSWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:COURTNEY
Other - Middle Name:LEIGH
Other - Last Name:MALAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-777-6935
Mailing Address - Fax:
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-4846
Practice Address - Fax:317-948-0126
Is Sole Proprietor?:No
Enumeration Date:2021-09-26
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28237991A163WP0200X
IN71013024A363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics