Provider Demographics
NPI:1851828636
Name:RADOSEVIC, KEELY ANNE
Entity Type:Individual
Prefix:
First Name:KEELY
Middle Name:ANNE
Last Name:RADOSEVIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KEELY
Other - Middle Name:ANNE
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:679 E COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1049
Mailing Address - Country:US
Mailing Address - Phone:317-807-1262
Mailing Address - Fax:317-859-4269
Practice Address - Street 1:1270 N POST RD STE A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-4254
Practice Address - Country:US
Practice Address - Phone:317-895-6095
Practice Address - Fax:317-895-6195
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28198674A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1487680518OtherGROUP NPI
IN677730OtherGROUP PTAN