Provider Demographics
NPI:1396205753
Name:DEEDS, MACY MANDELINE (APRN)
Entity Type:Individual
Prefix:
First Name:MACY
Middle Name:MANDELINE
Last Name:DEEDS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MACY
Other - Middle Name:MANDLINE
Other - Last Name:STORK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:1001 S OHIO ST
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401-5364
Mailing Address - Country:US
Mailing Address - Phone:785-827-6453
Mailing Address - Fax:785-823-1255
Practice Address - Street 1:1001 S OHIO ST
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-5364
Practice Address - Country:US
Practice Address - Phone:785-827-6453
Practice Address - Fax:785-823-1255
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE112734363LF0000X
KS53-78509-051363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201248070BMedicaid