Provider Demographics
NPI:1639622772
Name:DEKONINCK, PAMELA S (MS, RN, AGPCNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:S
Last Name:DEKONINCK
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Gender:F
Credentials:MS, RN, AGPCNP-BC
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Mailing Address - Street 1:2101 E COLISEUM BLVD
Mailing Address - Street 2:WU 234
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-1445
Mailing Address - Country:US
Mailing Address - Phone:260-481-5748
Mailing Address - Fax:260-481-5752
Practice Address - Street 1:2101 E COLISEUM BLVD
Practice Address - Street 2:WU 234
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1445
Practice Address - Country:US
Practice Address - Phone:260-481-5748
Practice Address - Fax:260-481-5752
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-25
Last Update Date:2016-07-25
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Provider Licenses
StateLicense IDTaxonomies
IN28079817363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology