Healthcare Provider Details

I. General information

NPI: 1346957917
Provider Name (Legal Business Name): CARISSA VANCAMP NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2445 S 350 W
COLUMBIA CITY IN
46725-9728
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-248-1701
  • Fax: 260-234-3292
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71013296A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28206591A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: