1548389752 NPI number — MARCIA LYNNE SHROCK APRN

Table of content: MARCIA LYNNE SHROCK APRN (NPI 1548389752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548389752 NPI number — MARCIA LYNNE SHROCK APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHROCK
Provider First Name:
MARCIA
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
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:
1548389752
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
122 N WATTERSON TRL
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:
40243-2700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-314-7050
Provider Business Mailing Address Fax Number:
502-245-7992

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
122 N WATTERSON TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40243-2700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-314-7050
Provider Business Practice Location Address Fax Number:
502-245-7992
Provider Enumeration Date:
03/28/2007

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:  5009232 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 201505322NP-PP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: CNP151106 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 18795 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 99063696A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 124312 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 02529 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP2300X , with the licence number: COA.14296-NP , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 3004426 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 18795 . This is a "STATE ARNP LICENSE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 201504071RN . This is a "OR RN LICENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 201505322NP-PP . This is a "OR NP LICENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 3004426 . This is a "STATE APRN LICENSE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: COA.14296-NP . This is a "STATE NP LICENSE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 5009232 . This is a "NC NP LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7100214550 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 71005296A . This is a "IN NP LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: CNP151106 . This is a "NP LICENSE" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: CNP-02529 . This is a "STATE ARNP LICENSE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: AP124312 . This is a "STATE ARNP LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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