Provider Demographics
NPI:1205117454
Name:MASSIE, DEANNA L (CNS)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:L
Last Name:MASSIE
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:L
Other - Last Name:BILKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3514
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:7910 W JEFFERSON BLVD STE 112
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4159
Practice Address - Country:US
Practice Address - Phone:260-969-7121
Practice Address - Fax:260-407-4330
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003492A364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01102663OtherRAILROAD MEDICARE
IN201031980Medicaid
OH0070146Medicaid
IN260690014Medicare PIN