Healthcare Provider Details

I. General information

NPI: 1750108726
Provider Name (Legal Business Name): DANIELLE ELISE FEDDELER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1923 W GLEN PARK AVE
GRIFFITH IN
46319-3703
US

IV. Provider business mailing address

1923 W GLEN PARK AVE
GRIFFITH IN
46319-3703
US

V. Phone/Fax

Practice location:
  • Phone: 219-922-2535
  • Fax:
Mailing address:
  • Phone: 219-922-2535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28237872A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71015875A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: