Provider Demographics
NPI:1063050185
Name:PETERS, CAROL DIANE (RN, CDE)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:DIANE
Last Name:PETERS
Suffix:
Gender:F
Credentials:RN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58725 STELLA DR
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46517-9438
Mailing Address - Country:US
Mailing Address - Phone:574-612-4870
Mailing Address - Fax:
Practice Address - Street 1:600 EAST BLVD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2483
Practice Address - Country:US
Practice Address - Phone:574-523-3126
Practice Address - Fax:574-296-2920
Is Sole Proprietor?:No
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN21600264163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator