Provider Demographics
NPI:1083394712
Name:LIZAK, JOANNA K
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:K
Last Name:LIZAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 W COLLEGE CORNER RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47330-1167
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2025 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-2971
Practice Address - Country:US
Practice Address - Phone:765-827-8064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-18
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28178390A363LP0808X
IN71014360A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health