Healthcare Provider Details

I. General information

NPI: 1255624912
Provider Name (Legal Business Name): CONNIE S. COLE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CONNIE S. CARUNCHIA NP-C

II. Dates (important events)

Enumeration Date: 05/27/2011
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 E 500 N
KENDALLVILLE IN
46755-9349
US

IV. Provider business mailing address

5900 E 500 N
KENDALLVILLE IN
46755-9349
US

V. Phone/Fax

Practice location:
  • Phone: 260-349-8185
  • Fax:
Mailing address:
  • Phone: 260-347-5630
  • Fax: 888-347-0088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number71003622A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71003622A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: