Provider Demographics
NPI:1699322446
Name:KEULTJES, EVELIN (NP)
Entity type:Individual
Prefix:
First Name:EVELIN
Middle Name:
Last Name:KEULTJES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:EVELIN
Other - Middle Name:
Other - Last Name:HERRERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12015 PEACOCK CIR
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-9511
Mailing Address - Country:US
Mailing Address - Phone:574-276-8690
Mailing Address - Fax:
Practice Address - Street 1:1815 E IRELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2845
Practice Address - Country:US
Practice Address - Phone:574-647-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28216118A363L00000X
IN71009377A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner