Basic Information
| Provider Information | |||||||||
| NPI: | 1578178331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STALETS | ||||||||
| FirstName: | MAKENZIE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9011 N MERIDIAN ST STE 225 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462605365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175744747 | ||||||||
| FaxNumber: | 3175744737 | ||||||||
| Practice Location | |||||||||
| Address1: | 8205 E 56TH ST STE 250 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462161097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173538985 | ||||||||
| FaxNumber: | 3173532389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2020 | ||||||||
| LastUpdateDate: | 02/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 10003081A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 300045170 | 05 | IN | MEDICAID | 10003081A | 01 | IN | PA LICENSE | OTHER |