Provider Demographics
NPI:1962467514
Name:DEEDS, VICKIE (NP)
Entity Type:Individual
Prefix:MS
First Name:VICKIE
Middle Name:
Last Name:DEEDS
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 1:3400 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-2295
Mailing Address - Country:US
Mailing Address - Phone:574-722-9633
Mailing Address - Fax:574-722-5987
Practice Address - Street 1:3400 E MARKET ST
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-2295
Practice Address - Country:US
Practice Address - Phone:574-722-9633
Practice Address - Fax:574-722-5987
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000409A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200340830Medicaid
IN221480BMedicare PIN
IN940670B1Medicare PIN
IN200340830Medicaid