Provider Demographics
NPI:1265971840
Name:KOLACZ, SARAH ANN (NP)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:ANN
Last Name:KOLACZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11652 DRAGOON TRL
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-9734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12563 STATE ROAD 23
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-9226
Practice Address - Country:US
Practice Address - Phone:574-335-8300
Practice Address - Fax:574-335-0775
Is Sole Proprietor?:No
Enumeration Date:2017-02-16
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007020A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300005019Medicaid
IN187720012OtherMEDICARE
INP01849424OtherRAILROAD MEDICARE
IN300005019Medicaid