1700901477 NPI number — LISA LORRAINE MLNARIK APRN

Table of content: LISA LORRAINE MLNARIK APRN (NPI 1700901477)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700901477 NPI number — LISA LORRAINE MLNARIK APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MLNARIK
Provider First Name:
LISA
Provider Middle Name:
LORRAINE
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:
JOHNSON
Provider Other First Name:
LISA
Provider Other Middle Name:
LORRAINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700901477
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
51415 851ST RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68726-5273
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-340-0462
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 N 29TH ST
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68701-4424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-844-8284
Provider Business Practice Location Address Fax Number:
402-644-7505
Provider Enumeration Date:
03/20/2007

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: 163W00000X , with the licence number:  54950 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 110462 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10025561900 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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