Healthcare Provider Details

I. General information

NPI: 1164146072
Provider Name (Legal Business Name): ELITE FAMILY NURSE PRACTITIONERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2022
Last Update Date: 10/04/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 W INDIANA AVE
CHESTERTON IN
46304-2350
US

IV. Provider business mailing address

407 W INDIANA AVE
CHESTERTON IN
46304-2350
US

V. Phone/Fax

Practice location:
  • Phone: 219-728-6562
  • Fax: 219-728-6564
Mailing address:
  • Phone: 219-728-6562
  • Fax: 219-728-6564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: AMANDA JOY DECH
Title or Position: FNP/OWNER
Credential: MSN/FNP-C
Phone: 219-728-6562