Provider Demographics
NPI:1255624912
Name:COLE, CONNIE S (NP-C)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:S
Last Name:COLE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:S
Other - Last Name:CARUNCHIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:5900 E 500 N
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-9349
Mailing Address - Country:US
Mailing Address - Phone:260-347-5630
Mailing Address - Fax:888-347-0088
Practice Address - Street 1:5900 E 500 N
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-9349
Practice Address - Country:US
Practice Address - Phone:260-349-8185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003622A363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01055058OtherRR MEDICARE
IN201023770Medicaid
INM400049519Medicare PIN