Provider Demographics
NPI:1619922150
Name:CARSON, ALLIE MARTISSA (NP)
Entity Type:Individual
Prefix:
First Name:ALLIE
Middle Name:MARTISSA
Last Name:CARSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13050 PARKSIDE DR STE 101
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-8247
Practice Address - Country:US
Practice Address - Phone:317-621-2290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001886A363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200845300Medicaid
INP01197278OtherRR MEDICARE PTAN
IN266180402Medicare PIN
INM400038467Medicare PIN
INM400038472Medicare PIN
INM400038451Medicare PIN
IN265900FMedicare PIN
INP01197278OtherRR MEDICARE PTAN
INM400053532Medicare PIN
INM400038478Medicare PIN
INM400038479Medicare PIN