Provider Demographics
NPI:1144664665
Name:VANCE, DEETTA KAY (APRN, FNP-BC, PMHNP-)
Entity type:Individual
Prefix:
First Name:DEETTA
Middle Name:KAY
Last Name:VANCE
Suffix:
Gender:F
Credentials:APRN, FNP-BC, PMHNP-
Other - Prefix:
Other - First Name:DEETTA
Other - Middle Name:KAY
Other - Last Name:CLOUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5493 GAINESWAY DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-9096
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1167 WILSON DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-8221
Practice Address - Country:US
Practice Address - Phone:317-363-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-26
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28178817A163W00000X, 363LP0808X
MO2012023980163W00000X
KS120654163WH1000X
MO2014002636363LF0000X
KS5376265111363LF0000X
IN71004949A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WH1000XNursing Service ProvidersRegistered NurseHospice
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201236490Medicaid
INP01456904OtherMEDICARE RR
IN266180500Medicare PIN