Individual
KELLY A MANICKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
7250 CLEARVISTA DR STE 355, INDIANAPOLIS, IN 46256-5609
(317) 621-5676
Mailing address
6626 E 75TH ST, SUITE 500, INDIANAPOLIS, IN 46250-2890
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
28164416
IN
363L00000X
Nurse Practitioner
71002746A
IN
363LA2200X
Adult Health Nurse Practitioner
Primary
71002746A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000622179
ANTHEM PROVIDER NUMBER
IN
05
—
200920210
—
IN
01
—
P00774860
RAILROAD MEDICARE
IN
01
—
P01678952
MEDICARE RAILROAD PTAN
IN
Enumeration date
09/16/2008
Last updated
04/30/2018
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