Healthcare Provider Details

I. General information

NPI: 1518369883
Provider Name (Legal Business Name): REBECCA SUE HERROLD-ENGSTROM MSN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 07/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 GLENDALE BLVD STE 103
VALPARAISO IN
46383
US

IV. Provider business mailing address

1101 GLENDALE BLVD STE 103
VALPARAISO IN
46383-3769
US

V. Phone/Fax

Practice location:
  • Phone: 219-464-9054
  • Fax: 219-465-1749
Mailing address:
  • Phone: 219-464-9054
  • Fax: 219-465-1749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71005207A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number71005207A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: