Provider Demographics
NPI:1679508410
Name:SCHALLMO, MARIANNE K (ANP)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:K
Last Name:SCHALLMO
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8895 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7037
Mailing Address - Country:US
Mailing Address - Phone:219-738-2081
Mailing Address - Fax:219-736-4658
Practice Address - Street 1:8895 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7037
Practice Address - Country:US
Practice Address - Phone:219-738-2081
Practice Address - Fax:219-736-4658
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28115564A363L00000X, 364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200805890Medicaid