Provider Demographics
NPI:1588616627
Name:NEVEL, ETTA KATHRYN (MD)
Entity Type:Individual
Prefix:
First Name:ETTA
Middle Name:KATHRYN
Last Name:NEVEL
Suffix:
Gender:F
Credentials:MD
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 1:315 E ELM ST STE 310
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4881
Practice Address - Country:US
Practice Address - Phone:208-454-2035
Practice Address - Fax:208-454-1065
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN70981207V00000X
IDMC-0237207V00000X
IN01027832A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100083520AMedicaid
238760CMedicare ID - Type Unspecified
IN100083520AMedicaid