Provider Demographics
NPI:1538048376
Name:DOMENECH, KELLY R (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:DOMENECH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:355 W 16TH ST STE 2800
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-2279
Mailing Address - Country:US
Mailing Address - Phone:317-963-7300
Mailing Address - Fax:317-963-7075
Practice Address - Street 1:355 W 16TH ST STE 2800
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2279
Practice Address - Country:US
Practice Address - Phone:317-963-7300
Practice Address - Fax:317-963-7075
Is Sole Proprietor?:No
Enumeration Date:2025-08-27
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71017023A363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner