Provider Demographics
NPI:1396463956
Name:GUTGSELL, DIANE NICOLE (PHARMD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:NICOLE
Last Name:GUTGSELL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12853 SLASH PASS
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-0062
Mailing Address - Country:US
Mailing Address - Phone:812-881-1741
Mailing Address - Fax:
Practice Address - Street 1:1717 S CALHOUN ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-5257
Practice Address - Country:US
Practice Address - Phone:260-458-2641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-19
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302414434183500000X
IN26030090A1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26030090AOtherPHARMACIST LICENSE
MI5302414434OtherPHARMACIST LICENSE NUMBER