Provider Demographics
NPI:1568433746
Name:DEARMOND, BRENDA KAYE (NP)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:KAYE
Last Name:DEARMOND
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6119 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-3072
Mailing Address - Country:US
Mailing Address - Phone:260-432-1568
Mailing Address - Fax:260-432-4969
Practice Address - Street 1:500 W VOTAW ST STE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-1322
Practice Address - Country:US
Practice Address - Phone:260-726-4350
Practice Address - Fax:260-726-9340
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28136923A163W00000X
INF1005131363L00000X
IN71002117A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00396106OtherMEDICARE RAILROAD
INP00396106Medicare PIN
Q55222Medicare UPIN
IN981270OOMedicare PIN