Provider Demographics
NPI:1245380070
Name:DEPEW, ELIZABETH RENE (MSN, FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:RENE
Last Name:DEPEW
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:3702 NEW VISION DR BLDG B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1234 E DUPONT RD
Practice Address - Street 2:SUITE 6
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1545
Practice Address - Country:US
Practice Address - Phone:260-480-2600
Practice Address - Fax:260-496-8077
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28141226A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN3123819OtherOH MEDICIAD
IN000000799124OtherANTHEM
IN188220OtherPTAN
IN200891390Medicaid
IN000000799124OtherANTHEM
IN3123819OtherOH MEDICIAD