Healthcare Provider Details

I. General information

NPI: 1669936498
Provider Name (Legal Business Name): KRISTA S NGUYEN NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2019
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3691 WILLOWCREEK RD
PORTAGE IN
46368-5076
US

IV. Provider business mailing address

601 GATEWAY BLVD N
CHESTERTON IN
46304-9658
US

V. Phone/Fax

Practice location:
  • Phone: 219-921-1444
  • Fax:
Mailing address:
  • Phone: 219-921-1359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number28197848A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: