Provider Demographics
NPI:1790023372
Name:KMIECIK, KELSEY L (NP)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:L
Last Name:KMIECIK
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:L
Other - Last Name:STOLLER
Other - Suffix:
Other - Last Name Type:Former Name
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 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-9981
Practice Address - Fax:317-944-0282
Is Sole Proprietor?:No
Enumeration Date:2013-01-16
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007825A363LP0200X
IL209.010123363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001174600OtherANTHEM PTAN
IN300013700Medicaid