Provider Demographics
NPI:1902061229
Name:HOUCK, SALLY A (NP)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:A
Last Name:HOUCK
Suffix:
Gender:F
Credentials:NP
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Other - First Name:
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Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 - PROVIDER ENROLLMENT
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 1:1701 N SENATE BLVD
Practice Address - Street 2:ROOM 7201
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-962-5455
Practice Address - Fax:317-962-5768
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-25
Last Update Date:2021-02-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN71002913A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201097080Medicaid