Provider Demographics
NPI:1780178616
Name:EDSALL, KELLY J (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:EDSALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-7588
Mailing Address - Fax:
Practice Address - Street 1:7250 CLEARVISTA DR STE 260
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-4686
Practice Address - Country:US
Practice Address - Phone:317-621-1695
Practice Address - Fax:317-621-1699
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2023-11-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN28189674A163W00000X
IN71008649A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300021436Medicaid