Provider Demographics
NPI:1871975029
Name:SHEETS, DUSTIN DE'WAYNE (PRESIDENT-CEO / IDE)
Entity type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:DE'WAYNE
Last Name:SHEETS
Suffix:
Gender:M
Credentials:PRESIDENT-CEO / IDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 HOSBROOK ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-1067
Mailing Address - Country:US
Mailing Address - Phone:317-646-8105
Mailing Address - Fax:
Practice Address - Street 1:1020 HOSBROOK ST
Practice Address - Street 2:SUITE D
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203-1067
Practice Address - Country:US
Practice Address - Phone:317-646-8105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0480-12-5874347C00000X
INQMA1400100374700000X
INHHA1204113374U00000X
INCNA0605779376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No374700000XNursing Service Related ProvidersTechnician
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide