Basic Information
| Provider Information | |||||||||
| NPI: | 1174893531 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GEPHART | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6920 POINTE INVERNESS WAY STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604793514 | ||||||||
| FaxNumber: | 2604793520 | ||||||||
| Practice Location | |||||||||
| Address1: | 7900 W JEFFERSON BLVD STE 304 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604583600 | ||||||||
| FaxNumber: | 2604583601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2012 | ||||||||
| LastUpdateDate: | 09/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71003834A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 000000744783 | 01 | IN | ANTHEM BCBS | OTHER | 71003834A | 01 | IN | INDIANA PROFESSIONAL NURSING BOARD LICENSE | OTHER | 201044550 | 05 | IN | MEDICAID |