Basic Information
Provider Information | |||||||||
NPI: | 1164486239 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MELVIN | ||||||||
FirstName: | JULIE | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | COOK | ||||||||
OtherFirstName: | JULIE | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6626 E 75TH ST | ||||||||
Address2: | SUITE 500 | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462502805 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7150 CLEARVISTA DR | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462561695 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3176215890 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/14/2006 | ||||||||
LastUpdateDate: | 09/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 28109739A | IN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 1164486239 | 01 |   | NPI | OTHER | 200250060 | 05 | IN |   | MEDICAID |