Provider Demographics
NPI:1720961022
Name:CHEATHAM, KENEDI (PA-C)
Entity type:Individual
Prefix:
First Name:KENEDI
Middle Name:
Last Name:CHEATHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3524 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-4486
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3524 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-4486
Practice Address - Country:US
Practice Address - Phone:317-925-0653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-26
Last Update Date:2025-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10004918A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant