Provider Demographics
NPI:1790293843
Name:KIRKWOOD, KATELYN ROSE (PA)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:ROSE
Last Name:KIRKWOOD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:ROSE
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:8111 S EMERSON AVE STE 204
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8601
Practice Address - Country:US
Practice Address - Phone:317-528-2555
Practice Address - Fax:317-528-2566
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2023-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002322A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant