Provider Demographics
NPI:1255422366
Name:BROCK, LISA ANNE (APRN-BC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:BROCK
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANNE
Other - Last Name:HARBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN-BC
Mailing Address - Street 1:12201 BLUEGRASS PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2361
Mailing Address - Country:US
Mailing Address - Phone:502-568-7366
Mailing Address - Fax:502-568-7114
Practice Address - Street 1:4301 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-1190
Practice Address - Country:US
Practice Address - Phone:765-282-0053
Practice Address - Fax:765-282-3290
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001294A363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000507763OtherBCBS
IN200839670Medicaid
IN000000507763OtherBCBS
ININ2048002Medicare PIN
IN249290BMedicare ID - Type UnspecifiedMEDICARE #
IN249290BMedicare ID - Type UnspecifiedMEDICARE #