Provider Demographics
NPI:1649895285
Name:EDGE, KELLY JEAN (CGC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:EDGE
Suffix:
Gender:
Credentials:CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1002 WISHARD BLVD STE 1100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-4164
Practice Address - Country:US
Practice Address - Phone:317-944-3966
Practice Address - Fax:317-968-1354
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN74000347A170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1102194716OtherANTHEM PTAN
IN300041098Medicaid
IN000001424534OtherANTHEM PTAN