MEDICARE: CAROLE A TENGBLAD FNP

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	363LF0000X	Family Nurse Practitioner	71001223A	IN

General Provider Information

NPI Number	:	1982603072
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLE A TENGBLAD FNP

Provider Business Mailing Address
First Line	:	1190 N STATE ROAD 49
Second Line	:
City	:	PORTER
State	:	IN
Zip	:	46304-1368
Country	:	US
Telephone Number	:	219-926-2146
Fax Number	:	219-926-3721

Provider Business Practice Location Address
First Line	:	1190 N STATE ROAD 49
Second Line	:
City	:	PORTER
State	:	IN
Zip	:	46304-1368
Country	:	US
Telephone Number	:	219-926-2146
Fax Number	:	219-926-3721

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

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	07/08/2007

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