Provider Demographics
NPI:1790191625
Name:SCHOEFFEL-GRAMMER, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SCHOEFFEL-GRAMMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11400 S. BROADWAY AVENUE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7106
Mailing Address - Country:US
Mailing Address - Phone:219-661-8680
Mailing Address - Fax:
Practice Address - Street 1:11400 BROADWAY
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7106
Practice Address - Country:US
Practice Address - Phone:219-661-8680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-11
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT20900212225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1356551634Medicare UPIN
IN1780691907Medicare UPIN
IN1063645752Medicare UPIN
IN1942217245Medicare UPIN