Healthcare Provider Details

I. General information

NPI: 1558162941
Provider Name (Legal Business Name): MARIELA CAROLINA SANTOS CARBALLO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2025
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7905 CALUMET AVE
MUNSTER IN
46321-2549
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-5800
  • Fax: 219-836-5030
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71016444A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: