Provider Demographics
NPI:1376948547
Name:VALDEZ, CAROL (NP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:VALDEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 E CEDAR ST
Mailing Address - Street 2:STE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:574-335-0760
Practice Address - Street 1:60101 BODNAR BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-9328
Practice Address - Country:US
Practice Address - Phone:574-335-8500
Practice Address - Fax:574-335-0794
Is Sole Proprietor?:No
Enumeration Date:2014-10-29
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28181527A163WE0003X
IN71005360363L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000919791OtherBCBS
IN201281160Medicaid
IN201281160Medicaid