1306867940 NPI number — LORI A YOUNG NP

Table of content: LORI A YOUNG NP (NPI 1306867940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306867940 NPI number — LORI A YOUNG NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
LORI
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306867940
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7950 W JEFFERSON BLVD
Provider Second Line Business Mailing Address:
SUITE 2121
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46804-4140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-407-8000
Provider Business Mailing Address Fax Number:
260-407-8004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 PROVIDENT DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARSAW
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46580-3297
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-372-7637
Provider Business Practice Location Address Fax Number:
574-372-7689
Provider Enumeration Date:
07/21/2006

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: 363L00000X , with the licence number:  71001143 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 71001143A , 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: 200329130 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com