Provider Demographics
NPI:1356093116
Name:BROOKS, HALLIE LANE (AGACNP)
Entity type:Individual
Prefix:
First Name:HALLIE
Middle Name:LANE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:HALLIE
Other - Middle Name:LANE
Other - Last Name:VASCHAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 N SENATE BLVD STE 635
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-962-0585
Practice Address - Fax:317-962-2082
Is Sole Proprietor?:No
Enumeration Date:2022-01-24
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28238078A163W00000X
390200000X
IN71012157A363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program