Healthcare Provider Details

I. General information

NPI: 1073180139
Provider Name (Legal Business Name): MICHELE CHRISTINE KOTIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 03/05/2023
Certification Date: 03/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9307 CALUMET AVE STE D1
MUNSTER IN
46321-2892
US

IV. Provider business mailing address

13458 W 83RD PL
SAINT JOHN IN
46373-9169
US

V. Phone/Fax

Practice location:
  • Phone: 121-970-3939
  • Fax: 219-703-6704
Mailing address:
  • Phone: 219-775-3839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71011185A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: