Provider Demographics
NPI:1730579525
Name:BRACKIN, DIANE LYNN (NP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:LYNN
Last Name:BRACKIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:LYNN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9894 E 121ST ST
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-4154
Practice Address - Country:US
Practice Address - Phone:317-621-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-31
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005606A363LG0600X
IN28124384A163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01512462OtherRR MEDICARE
IN201313080Medicaid
INP01512462OtherRR MEDICARE