Provider Demographics
NPI:1104268432
Name:MISBACH, KENDRA A (FNP-C)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:A
Last Name:MISBACH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6983 HILLSDALE CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2054
Mailing Address - Country:US
Mailing Address - Phone:317-308-2800
Mailing Address - Fax:317-576-6311
Practice Address - Street 1:1601 MEDICAL ARTS BLVD
Practice Address - Street 2:STE 102
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-3434
Practice Address - Country:US
Practice Address - Phone:765-298-4545
Practice Address - Fax:765-298-4945
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004574A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201183850Medicaid
INP01403068OtherRAILROAD MEDICARE
INM22404019Medicare PIN