Basic Information
| Provider Information | |||||||||
| NPI: | 1679508410 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHALLMO | ||||||||
| FirstName: | MARIANNE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8895 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197382081 | ||||||||
| FaxNumber: | 2197364658 | ||||||||
| Practice Location | |||||||||
| Address1: | 8895 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197382081 | ||||||||
| FaxNumber: | 2197364658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 01/20/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 28115564A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364S00000X | 28115564A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
ID Information
| ID | Type | State | Issuer | Description | 200805890 | 05 | IN | MEDICAID |