Healthcare Provider Details

I. General information

NPI: 1891024261
Provider Name (Legal Business Name): SCARLET RAE SPAIN MSN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2009
Last Update Date: 10/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 WATLING ST MEDICAL DEPT. 8-210
EAST CHICAGO IN
46312-1716
US

IV. Provider business mailing address

3210 WATLING ST MEDICAL DEPT. 8-210
EAST CHICAGO IN
46312-1716
US

V. Phone/Fax

Practice location:
  • Phone: 219-399-3133
  • Fax: 219-399-5814
Mailing address:
  • Phone: 219-399-3133
  • Fax: 219-399-5814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28160228A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: