Healthcare Provider Details

I. General information

NPI: 1477491900
Provider Name (Legal Business Name): GRACE SEBELLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2026
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N 26TH ST
LAFAYETTE IN
47904-2895
US

IV. Provider business mailing address

9371 N 408 E
LAKE VILLAGE IN
46349-9248
US

V. Phone/Fax

Practice location:
  • Phone: 866-682-5539
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71017901A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number71017901A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: