Basic Information
| Provider Information | |||||||||
| NPI: | 1043321672 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLADD | ||||||||
| FirstName: | NEELY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 524 BRANCH CT | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467251323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602446203 | ||||||||
| FaxNumber: | 2602445212 | ||||||||
| Practice Location | |||||||||
| Address1: | 524 BRANCH CT | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467251323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602446203 | ||||||||
| FaxNumber: | 2602445212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 04/18/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71001997A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 000000528916 | 01 | IN | ANTHEM | OTHER | 351972384039 | 01 | IN | TRICARE | OTHER |