Provider Demographics
NPI:1649378647
Name:NAWA, KATHLEEN A (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:NAWA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:A
Other - Last Name:DIEKHOFF
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:317-274-1201
Mailing Address - Fax:317-278-9905
Practice Address - Street 1:705 RILEY HOSPITAL DRIVE
Practice Address - Street 2:RR 208
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-274-4715
Practice Address - Fax:317-274-2065
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002214363L00000X
GARN311453363LN0000X
IN28150969363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200884310Medicaid