Provider Demographics
NPI:1114588076
Name:SAMPLE, LINDSEY LEANN (MSN, AG-ACNP)
Entity Type:Individual
Prefix:MRS
First Name:LINDSEY
Middle Name:LEANN
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:MSN, AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2022 KELLE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-8708
Mailing Address - Country:US
Mailing Address - Phone:219-364-3616
Mailing Address - Fax:219-364-3610
Practice Address - Street 1:1101 GLENDALE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-3769
Practice Address - Country:US
Practice Address - Phone:219-464-9054
Practice Address - Fax:219-465-1749
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041437122163W00000X
IN28215273A163W00000X
IN71009567A363L00000X, 363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No163W00000XNursing Service ProvidersRegistered Nurse
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner