Basic Information
| Provider Information | |||||||||
| NPI: | 1902068547 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THIELKING | ||||||||
| FirstName: | BETH | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1026 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462061026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177776435 | ||||||||
| FaxNumber: | 3177776644 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 W 10TH ST | ||||||||
| Address2: | HS1001 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462023010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172748812 | ||||||||
| FaxNumber: | 3172740133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2008 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 28078636 | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 71002369 | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 201116970 | 05 | IN | MEDICAID |