Provider Demographics
NPI:1609176197
Name:CARLSON, MEGAN MARIE (PNP-BC)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:MARIE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 LAFAYETTE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-1146
Mailing Address - Country:US
Mailing Address - Phone:317-291-7422
Mailing Address - Fax:317-291-7433
Practice Address - Street 1:3400 LAFAYETTE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222-1146
Practice Address - Country:US
Practice Address - Phone:317-291-7422
Practice Address - Fax:317-291-7433
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-30
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.008391363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics