MEDICARE: CARISSA VANCAMP NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	28206591A	IN
2	363L00000X	Nurse Practitioner	71013296A	IN

General Provider Information

NPI Number	:	1346957917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARISSA VANCAMP NP

Provider Business Mailing Address
First Line	:	11109 PARKVIEW PLAZA DR # 117
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1701
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2445 S 350 W
Second Line	:
City	:	COLUMBIA CITY
State	:	IN
Zip	:	46725-9728
Country	:	US
Telephone Number	:	260-248-1701
Fax Number	:	260-234-3292

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2022
Last Update Date	:	06/17/2025

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