Healthcare Provider Details

I. General information

NPI: 1952734295
Provider Name (Legal Business Name): CARLEEN KAUCKY C-NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2013
Last Update Date: 05/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 SOUTH LAKE PARK AVE
HOBART IN
46342
US

IV. Provider business mailing address

1445 SOUTH LAKE PARK AVE
HOBART IN
46342
US

V. Phone/Fax

Practice location:
  • Phone: 219-942-7100
  • Fax: 219-945-0095
Mailing address:
  • Phone: 219-942-7100
  • Fax: 219-945-0095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.010203
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: