Provider Demographics
NPI:1548511413
Name:WELLS, COLETTE RAE (NP)
Entity type:Individual
Prefix:
First Name:COLETTE
Middle Name:RAE
Last Name:WELLS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:COLETTE
Other - Middle Name:RAE
Other - Last Name:FUQUA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:8333 NAAB RD STE 203
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-5924
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8333 NAAB RD STE 230
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1983
Practice Address - Country:US
Practice Address - Phone:317-415-6580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004164A363L00000X, 363LA2100X
TXAP134563363L00000X, 363LA2100X
TN21004363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1548511413Medicaid