Provider Demographics
NPI:1487948816
Name:CONNIE S CARUNCHIA PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:CONNIE S CARUNCHIA PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:260-349-8185
Mailing Address - Street 1:5900 E 500 N
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-9349
Mailing Address - Country:US
Mailing Address - Phone:260-349-8185
Mailing Address - Fax:888-347-0088
Practice Address - Street 1:5900 E 500 N
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-9349
Practice Address - Country:US
Practice Address - Phone:260-349-8185
Practice Address - Fax:888-347-0088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-02
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN55000068A363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201023750AMedicaid
DS6979OtherRR MEDICARE
DS6979OtherRR MEDICARE