Provider Demographics
NPI:1023013430
Name:DELERUYELLE, VICKIE LEA (CNP)
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:LEA
Last Name:DELERUYELLE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:151 ANDERSON LN
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:OH
Practice Address - Zip Code:45786-5312
Practice Address - Country:US
Practice Address - Phone:740-984-2332
Practice Address - Fax:740-984-4435
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP08290363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000370964OtherANTHEM
OH000000699818OtherANTHEM
OH2588543Medicaid
OHP00231317OtherRRMCR
WV3810002943Medicaid
OH000000699818OtherANTHEM
P91589Medicare UPIN
OH2588543Medicaid