Healthcare Provider Details

I. General information

NPI: 1376948547
Provider Name (Legal Business Name): CAROL VALDEZ N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2014
Last Update Date: 02/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60101 BODNAR BLVD SUITE B
MISHAWAKA IN
46544-9328
US

IV. Provider business mailing address

707 E CEDAR ST STE 200
SOUTH BEND IN
46617-2057
US

V. Phone/Fax

Practice location:
  • Phone: 574-335-8500
  • Fax: 574-335-0794
Mailing address:
  • Phone: 574-335-8700
  • Fax: 574-335-0760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number28181527A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71005360
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: