1104225739 NPI number — CARRIE DANIELS FNP

Table of content: (NPI 1831614502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104225739 NPI number — CARRIE DANIELS FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DANIELS
Provider First Name:
CARRIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104225739
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
710 N NILES AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46617-1924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-647-1610
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3301 COUNTY ROAD 6 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKHART
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46514-7673
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-264-9635
Provider Business Practice Location Address Fax Number:
574-262-0398
Provider Enumeration Date:
08/20/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  71005105A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000895822 . This is a "BCBS BMG ELKHART" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 201253830 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01407944 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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