Provider Demographics
NPI:1164134136
Name:WALDKOETTER, EMILY MARIE (PA STUDENT)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:MARIE
Last Name:WALDKOETTER
Suffix:
Gender:F
Credentials:PA STUDENT
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:MARIE
Other - Last Name:GUERRERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2022 KELLE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-8708
Mailing Address - Country:US
Mailing Address - Phone:219-364-3600
Mailing Address - Fax:219-364-3210
Practice Address - Street 1:2505 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2715
Practice Address - Country:US
Practice Address - Phone:219-548-3843
Practice Address - Fax:219-548-3256
Is Sole Proprietor?:No
Enumeration Date:2022-12-21
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT390200000X
IN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program