Provider Demographics
NPI:1063467371
Name:RUTAN, GAIL L (NP)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:L
Last Name:RUTAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:GAIL
Other - Middle Name:L
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:2600 GREENBUSH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2477
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001551A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INPENDINGOtherANTHEM PROVIDER NUMBER
IN200534870Medicaid
IN815500S5Medicare PIN
IN200534870Medicaid