Provider Demographics
NPI:1154401230
Name:GAYED, VICKIE JEAN (NP)
Entity type:Individual
Prefix:MRS
First Name:VICKIE
Middle Name:JEAN
Last Name:GAYED
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:2003 STULTS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:HUNTINGTON
Practice Address - State:IN
Practice Address - Zip Code:46750-1291
Practice Address - Country:US
Practice Address - Phone:260-356-5424
Practice Address - Fax:260-358-2090
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000442A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000655782OtherANTHEM
IN200302300AMedicaid
IN200956680Medicaid
INM400019334Medicare PIN
IN000000655782OtherANTHEM
INA17512Medicare UPIN
IN200956680Medicaid