Healthcare Provider Details

I. General information

NPI: 1952890352
Provider Name (Legal Business Name): ISRAEL NIETO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2018
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 BROADWAY
GARY IN
46408-4605
US

IV. Provider business mailing address

PO BOX 746721
ATLANTA GA
30374-6721
US

V. Phone/Fax

Practice location:
  • Phone: 219-237-5170
  • Fax: 219-321-1931
Mailing address:
  • Phone: 773-352-1515
  • Fax: 312-929-0373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71007936A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: