Healthcare Provider Details

I. General information

NPI: 1962467514
Provider Name (Legal Business Name): VICKIE DEEDS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 E MARKET ST
LOGANSPORT IN
46947-2295
US

IV. Provider business mailing address

3400 E MARKET ST
LOGANSPORT IN
46947-2295
US

V. Phone/Fax

Practice location:
  • Phone: 574-722-9633
  • Fax: 574-722-5987
Mailing address:
  • Phone: 574-722-9633
  • Fax: 574-722-5987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71000409A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: