Provider Demographics
NPI:1578964169
Name:BACK, KATHERINE ANN (NP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANN
Last Name:BACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
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 1:2920 N ARLINGTON AVE STE B
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46218-3362
Practice Address - Country:US
Practice Address - Phone:317-355-9315
Practice Address - Fax:317-355-9319
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2023-02-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN71005150A363LA2200X
IN28198239A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ00416530OtherRAILROAD MEDICARE