1245380070 NPI number — MS. ELIZABETH RENE DEPEW MSN, FNP-BC

Table of content: MS. ELIZABETH RENE DEPEW MSN, FNP-BC (NPI 1245380070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245380070 NPI number — MS. ELIZABETH RENE DEPEW MSN, FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEPEW
Provider First Name:
ELIZABETH
Provider Middle Name:
RENE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSN, FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245380070
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3702 NEW VISION DR BLDG B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46845-1703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1234 E DUPONT RD
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46825-1545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-480-2600
Provider Business Practice Location Address Fax Number:
260-496-8077
Provider Enumeration Date:
01/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  28141226A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3123819 . This is a "OH MEDICIAD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000799124 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 188220 . This is a "PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200891390 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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