Provider Demographics
NPI:1154633790
Name:THE FOOT CARE NURSE LLC
Entity Type:Organization
Organization Name:THE FOOT CARE NURSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUZAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VON EHR
Authorized Official - Suffix:
Authorized Official - Credentials:FNP, APRN-BC
Authorized Official - Phone:219-707-9237
Mailing Address - Street 1:2410 ALLISON CIR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-3973
Mailing Address - Country:US
Mailing Address - Phone:219-707-9237
Mailing Address - Fax:219-961-8300
Practice Address - Street 1:2410 ALLISON CIR
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-3973
Practice Address - Country:US
Practice Address - Phone:219-707-9237
Practice Address - Fax:219-961-8300
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE FOOT CARE NURSE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-12
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000056A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INS56770Medicare UPIN