Provider Demographics
NPI:1306867940
Name:YOUNG, LORI A (NP)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:YOUNG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7950 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 2121
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4140
Mailing Address - Country:US
Mailing Address - Phone:260-407-8000
Mailing Address - Fax:260-407-8004
Practice Address - Street 1:1500 PROVIDENT DR STE A
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3297
Practice Address - Country:US
Practice Address - Phone:574-372-7637
Practice Address - Fax:574-372-7689
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001143363L00000X
IN71001143A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200329130Medicaid
P34493Medicare UPIN
IN178650WMedicare ID - Type Unspecified
IN138420HHHHMedicare ID - Type Unspecified