Healthcare Provider Details

I. General information

NPI: 1265361828
Provider Name (Legal Business Name): COLLEEN CARRAE BENNETT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 E 1100 N
CHESTERTON IN
46304-9697
US

IV. Provider business mailing address

401 BARKER RD
MICHIGAN CITY IN
46360-7425
US

V. Phone/Fax

Practice location:
  • Phone: 219-926-3420
  • Fax:
Mailing address:
  • Phone: 219-299-9240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71018142A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: