Basic Information
| Provider Information | |||||||||
| NPI: | 1508826207 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176216300 | ||||||||
| FaxNumber: | 3176216310 | ||||||||
| Practice Location | |||||||||
| Address1: | 8202 CLEARVISTA PKWY | ||||||||
| Address2: | SUITE 7A | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462561445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176216300 | ||||||||
| FaxNumber: | 3176216310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2006 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 71000009A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 000000655113 | 01 | IN | ANTHEM | OTHER | 000000659326 | 01 | IN | ANTHEM | OTHER | 000000655709 | 01 | IN | ANTHEM | OTHER | 000000667919 | 01 | IN | ANTHEM | OTHER | 200963890 | 05 | IN | MEDICAID |