Provider Demographics
NPI:1730448622
Name:SHERIDAN, KRYSTIN CHANELLE (ANP)
Entity type:Individual
Prefix:
First Name:KRYSTIN
Middle Name:CHANELLE
Last Name:SHERIDAN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:KRYSTIN
Other - Middle Name:CHANELLE
Other - Last Name:HUTCHISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:8433 HARCOURT RD STE 100
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2193
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8433 HARCOURT RD STE 100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260
Practice Address - Country:US
Practice Address - Phone:317-583-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-11
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003987A363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201077320Medicaid
IN201077320Medicaid
INM400074272Medicare PIN