1255422366 NPI number — LISA ANNE BROCK APRN-BC

Table of content: LISA ANNE BROCK APRN-BC (NPI 1255422366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255422366 NPI number — LISA ANNE BROCK APRN-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROCK
Provider First Name:
LISA
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HARBER
Provider Other First Name:
LISA
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN-BC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255422366
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12201 BLUEGRASS PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40299-2361
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-568-7366
Provider Business Mailing Address Fax Number:
502-568-7114

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4301 N WALNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MUNCIE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47303-1190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-282-0053
Provider Business Practice Location Address Fax Number:
765-282-3290
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  71001294A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 71001294A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000507763 . This is a "BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200839670 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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