Provider Demographics
NPI:1154617850
Name:HECKLEY, SUSAN E (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:HECKLEY
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 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:MEDPARTNERS, ATTN: BARB COPELAND
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 1:7916 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-432-2297
Practice Address - Fax:260-434-6496
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000511A363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0050703Medicaid
IN200239090Medicaid
IN200239090Medicaid
IN260690005Medicare PIN