Individual ProviderGail L ShivelyNurse PractitionerPhysician Assistants & Advanced Practice Nursing ProvidersPractice Address7916 W Jefferson Blvd, Fort Wayne, IN 46804-4140(260) 432-2297(260) 479-3514PECOS EnrollmentBased on the most recent information from CMS, provider Gail L Shively does not have current enrollment records in PECOS.Part BMedicare Part BNot EnrolledHHAHome Health AgencyNot EnrolledDMEDurable Medical EquipmentNot EnrolledPMDPower Mobility DeviceNot EnrolledCMS last updated its PECOS records yesterday at 12:57 PM.Profile DetailsProvider ID1699792630Provider TypeIndividualFull NameShively, Gail LCredentialNPGenderFemaleSole ProprietorNoEnumeration Date7/16/2006Last Updated9/30/2020Contact InformationPractice LocationPractice Address7916 W Jefferson Blvd, Fort Wayne, IN 46804-4140Phone(260) 432-2297Fax(260) 479-2950Mailing LocationMailing Address6920 Pointe Inverness Way Ste 200, Fort Wayne, IN 46804-7934Phone(260) 479-3514Fax(260) 479-3520Provider TaxonomiesCodeDescriptionLicenseCode363LF0000XPrimaryDescriptionNurse PractitionerPhysician Assistants & Advanced Practice Nursing ProvidersLicense71002080AIndianaProvider IdentifiersIDDescriptionIssuerID200878280DescriptionMedicaidIssuerUnlistedIndiana