Basic Information
| Provider Information | |||||||||
| NPI: | 1215406152 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAMBARGER | ||||||||
| FirstName: | KAYLA | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176211647 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1550 E COUNTY LINE RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462270990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174972300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2018 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71008772A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | 28198617A | IN | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 300022796 | 05 | IN | MEDICAID |