Provider Demographics
NPI:1003057951
Name:HEAD, KACY YEVONNE (PA)
Entity type:Individual
Prefix:
First Name:KACY
Middle Name:YEVONNE
Last Name:HEAD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KACY
Other - Middle Name:YEVONNE
Other - Last Name:GRIFFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-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:317-859-4268
Practice Address - Street 1:100 HOSPITAL LN
Practice Address - Street 2:SUITE 105
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-1989
Practice Address - Country:US
Practice Address - Phone:317-745-3747
Practice Address - Fax:317-745-3748
Is Sole Proprietor?:No
Enumeration Date:2009-03-23
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA06217363A00000X
IN10001167A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000736707OtherANTHEM PIN
TX800N55OtherBCBS
TX202786401Medicaid
IN1487680518OtherGROUP NPI
TX800N55OtherBCBS
IN1487680518OtherGROUP NPI
TX202786401Medicaid