Basic Information
| Provider Information | |||||||||
| NPI: | 1376856278 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEGACY | ||||||||
| FirstName: | VALERIE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KAVANAUGH | ||||||||
| OtherFirstName: | VALERIE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1650 N COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179246351 | ||||||||
| FaxNumber: | 3179273098 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 ESKENAZI AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178800000 | ||||||||
| FaxNumber: | 3178800565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2010 | ||||||||
| LastUpdateDate: | 11/11/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 28098488 | IN | N | Nursing Service Providers | Registered Nurse | 163WG0100X | 28098488 | IN | N | Nursing Service Providers | Registered Nurse | Gastroenterology | 363LF0000X | 71003295A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 28098488 | 01 | IN | REGISTERED NURSE | OTHER |