Healthcare Provider Details

I. General information

NPI: 1548018377
Provider Name (Legal Business Name): KAELA FUNCHES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2024
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 GRANT ST
GARY IN
46404-3439
US

IV. Provider business mailing address

6056 FILLMORE PL
MERRILLVILLE IN
46410-7602
US

V. Phone/Fax

Practice location:
  • Phone: 219-763-8112
  • Fax:
Mailing address:
  • Phone: 708-679-4823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71015219A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: