Provider Demographics
NPI:1194768010
Name:GIFFORD, WANDA GAY (APRN-BC)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:GAY
Last Name:GIFFORD
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:118 W DREXEL PKWY
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-7344
Practice Address - Country:US
Practice Address - Phone:219-866-4300
Practice Address - Fax:219-866-7591
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000809A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200305970Medicaid
IN940930PMedicare PIN
INM400055682Medicare PIN
INP58055Medicare UPIN