Provider Demographics
NPI:1104225739
Name:DANIELS, CARRIE (FNP)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:DANIELS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:3301 COUNTY ROAD 6 E
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-7673
Practice Address - Country:US
Practice Address - Phone:574-264-9635
Practice Address - Fax:574-262-0398
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005105A363LF0000X
IN28185742A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000895822OtherBCBS BMG ELKHART
IN201253830Medicaid
INP01407944OtherRR MEDICARE
IN000000895823OtherBCBS MIDDLEBURY
IN201253830Medicaid
IN201253830Medicaid