Provider Demographics
NPI:1902112105
Name:SOMERVILLE, VERONICA M (NP)
Entity Type:Individual
Prefix:MRS
First Name:VERONICA
Middle Name:M
Last Name:SOMERVILLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:VERONICA
Other - Middle Name:M
Other - Last Name:SAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
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 1:1701 N SENATE BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-962-3886
Practice Address - Fax:317-962-5492
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28163090A363LF0000X
IN71003378A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201002140Medicaid
IN201002140Medicaid
INM400065018Medicare PIN
IN267030034Medicare PIN