Healthcare Provider Details

I. General information

NPI: 1376021725
Provider Name (Legal Business Name): KALEY MICHELLE MARINO APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2018
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 MOSSY LN
MISHAWAKA IN
46544-9055
US

IV. Provider business mailing address

9250 COLUMBIA AVE STE 2E
MUNSTER IN
46321-3530
US

V. Phone/Fax

Practice location:
  • Phone: 443-739-9997
  • Fax:
Mailing address:
  • Phone: 219-595-0043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71008172A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71008172A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: