Provider Demographics
NPI:1215949797
Name:WIKSE, KELLY N (PA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:N
Last Name:WIKSE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:CULLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:8501 HARCOURT RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2046
Mailing Address - Country:US
Mailing Address - Phone:317-875-9105
Mailing Address - Fax:317-808-8802
Practice Address - Street 1:8501 HARCOURT RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2046
Practice Address - Country:US
Practice Address - Phone:317-875-9105
Practice Address - Fax:317-808-8802
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000393A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10000393AOtherIN LICENSE
IN300016127Medicaid