Provider Demographics
NPI:1497035166
Name:CORCORAN, LORIE ANNE (APNP)
Entity Type:Individual
Prefix:
First Name:LORIE
Middle Name:ANNE
Last Name:CORCORAN
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:LORIE
Other - Middle Name:ANNE
Other - Last Name:TAZALLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
Mailing Address - Street 1:PO BOX 1567
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61110-0067
Mailing Address - Country:US
Mailing Address - Phone:779-696-7150
Mailing Address - Fax:779-696-7342
Practice Address - Street 1:1401 E STATE ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2315
Practice Address - Country:US
Practice Address - Phone:815-961-2460
Practice Address - Fax:815-967-5470
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009835363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care