Provider Demographics
NPI:1427425164
Name:LAGRANGE, CHELSEA NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:CHELSEA
Middle Name:NICOLE
Last Name:LAGRANGE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHELSEA
Other - Middle Name:NICOLE
Other - Last Name:FELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2605 E CREEKS EDGE DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8368
Practice Address - Country:US
Practice Address - Phone:812-333-2663
Practice Address - Fax:812-676-4131
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005666363A00000X
IN10003588A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881Medicare Oscar/Certification