Healthcare Provider Details

I. General information

NPI: 1003623117
Provider Name (Legal Business Name): LAURA BOLSEGA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S LAKE PARK AVE
HOBART IN
46342-6699
US

IV. Provider business mailing address

605 W 100 N
VALPARAISO IN
46385-9234
US

V. Phone/Fax

Practice location:
  • Phone: 219-947-6200
  • Fax: 219-947-6220
Mailing address:
  • Phone: 216-669-1828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28286785A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: