Healthcare Provider Details

I. General information

NPI: 1104973536
Provider Name (Legal Business Name): ELIZABETH DIANE SCHALLIOL N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NAVARRE PL STE 4470
SOUTH BEND IN
46601-1168
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-1405
  • Fax: 574-647-3970
Mailing address:
  • Phone: 574-647-2129
  • Fax: 574-237-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number71002043A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: