Provider Demographics
NPI:1073957593
Name:FOX, LISA M (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:FOX
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:BRAUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N. RITTER AVENUE
Practice Address - Street 2:SUITE 370
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3098
Practice Address - Country:US
Practice Address - Phone:317-355-1144
Practice Address - Fax:317-355-1155
Is Sole Proprietor?:No
Enumeration Date:2013-04-26
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28104395A363LA2100X
IN71004423A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000822694OtherANTHEM
IN201178520Medicaid
INP01261819OtherMEDICARE RR PTAN
IN000000822694OtherANTHEM