Healthcare Provider Details

I. General information

NPI: 1164064119
Provider Name (Legal Business Name): CORINNE MONIQUE HERTSEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CORINNE MONIQUE SHIELDS

II. Dates (important events)

Enumeration Date: 10/10/2019
Last Update Date: 10/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 W PICKWICK DR STE A
SYRACUSE IN
46567-1832
US

IV. Provider business mailing address

107 W PICKWICK DR STE A
SYRACUSE IN
46567-1832
US

V. Phone/Fax

Practice location:
  • Phone: 574-457-8585
  • Fax: 260-479-2913
Mailing address:
  • Phone: 574-457-8585
  • Fax: 260-479-2913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28173822A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71009435A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: