Healthcare Provider Details

I. General information

NPI: 1194282012
Provider Name (Legal Business Name): PAULA JEAN ROUSIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W 6TH AVE
GARY IN
46402-1711
US

IV. Provider business mailing address

1100 W 6TH AVE
GARY IN
46402-1711
US

V. Phone/Fax

Practice location:
  • Phone: 219-885-4246
  • Fax:
Mailing address:
  • Phone: 219-885-4624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2808733A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number2808733A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: