Provider Demographics
NPI:1164064119
Name:HERTSEL, CORINNE MONIQUE
Entity Type:Individual
Prefix:
First Name:CORINNE
Middle Name:MONIQUE
Last Name:HERTSEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CORINNE
Other - Middle Name:MONIQUE
Other - Last Name:SHIELDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:107 W PICKWICK DR STE A
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:IN
Mailing Address - Zip Code:46567-1832
Mailing Address - Country:US
Mailing Address - Phone:574-457-8585
Mailing Address - Fax:260-479-2913
Practice Address - Street 1:107 W PICKWICK DR STE A
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:IN
Practice Address - Zip Code:46567-1832
Practice Address - Country:US
Practice Address - Phone:574-457-8585
Practice Address - Fax:260-479-2913
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28173822A163W00000X
IN71009435A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse