Provider Demographics
NPI:1043253081
Name:CARLSON, KATHLEEN A (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:CARLSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 SONOMA CT
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-3748
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:761 45TH ST STE 103
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2899
Practice Address - Country:US
Practice Address - Phone:219-922-3002
Practice Address - Fax:219-922-3003
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN071000108A363LA2200X
IN71000108A207RR0500X
IN71000108363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200062110AMedicaid
IN200062110Medicaid
INP 10536Medicare UPIN
IN499500ZMedicare PIN