Provider Demographics
NPI:1710937289
Name:PICKENS, BETH ANNE (CPNP)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:ANNE
Last Name:PICKENS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 E RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-4744
Mailing Address - Country:US
Mailing Address - Phone:317-781-4900
Mailing Address - Fax:317-781-4868
Practice Address - Street 1:1633 N CAPITOL AVE STE 236
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1262
Practice Address - Country:US
Practice Address - Phone:317-962-8067
Practice Address - Fax:317-963-5038
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001328A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200441790Medicaid
IN715530V7Medicare PIN
IN200441790Medicaid