Provider Demographics
NPI:1659744126
Name:SULTZER, LATONYA L
Entity Type:Individual
Prefix:
First Name:LATONYA
Middle Name:L
Last Name:SULTZER
Suffix:
Gender:F
Credentials:
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 1:6910 HILLSDALE CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2040
Practice Address - Country:US
Practice Address - Phone:317-621-6337
Practice Address - Fax:317-621-6366
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-05
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28157480A261QP2300X
IN71006098A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN28157480AOtherINDIANA PROFESSIONAL LICENSING AGENCY NURSING BOARD
IN201346070Medicaid
INP01678747OtherRR MEDICARE
IN201346070Medicaid