Provider Demographics
NPI:1023431814
Name:VAGELATOS, AMANDA (NP-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:VAGELATOS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 173RD ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46323-2074
Mailing Address - Country:US
Mailing Address - Phone:765-494-0111
Mailing Address - Fax:
Practice Address - Street 1:2250 173RD ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46323-2074
Practice Address - Country:US
Practice Address - Phone:765-494-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-29
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28189650A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201214860Medicaid
IN71004816AOtherAPRN - INDIANA