Healthcare Provider Details

I. General information

NPI: 1437168622
Provider Name (Legal Business Name): SANDRA ELAINE SCHOLEBO RN, MSN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3190 LANCER ST
PORTAGE IN
46368
US

IV. Provider business mailing address

3190 LANCER ST
PORTAGE IN
46368-4488
US

V. Phone/Fax

Practice location:
  • Phone: 219-764-3600
  • Fax: 219-764-3661
Mailing address:
  • Phone: 219-764-3600
  • Fax: 219-764-3661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71000701
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: