Healthcare Provider Details

I. General information

NPI: 1396714226
Provider Name (Legal Business Name): CARLI J WIERSEMA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9330 BROADWAY
CROWN POINT IN
46307-8602
US

IV. Provider business mailing address

1326 LANTZ LN
SCHERERVILLE IN
46375-3028
US

V. Phone/Fax

Practice location:
  • Phone: 219-662-5000
  • Fax:
Mailing address:
  • Phone: 219-864-4350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71001182A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: