Basic Information
Provider Information | |||||||||
NPI: | 1497748263 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GERGEN | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | RAE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SIRONEN | ||||||||
OtherFirstName: | LISA | ||||||||
OtherMiddleName: | R. | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 560 S LOOP RD | ||||||||
Address2: |   | ||||||||
City: | EDGEWOOD | ||||||||
State: | KY | ||||||||
PostalCode: | 410173405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8593012663 | ||||||||
FaxNumber: | 8593010655 | ||||||||
Practice Location | |||||||||
Address1: | 560 S LOOP RD | ||||||||
Address2: |   | ||||||||
City: | EDGEWOOD | ||||||||
State: | KY | ||||||||
PostalCode: | 410173405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8593012663 | ||||||||
FaxNumber: | 8593010655 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/26/2005 | ||||||||
LastUpdateDate: | 02/03/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN-232372 | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 1067394 | KY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 3003813 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 2442191 | 01 |   | UHC | OTHER | 2535028 | 05 | OH |   | MEDICAID | 78008083 | 05 | KY |   | MEDICAID | 000000248062 | 01 |   | ANTHEM | OTHER | P65717 | 01 |   | UPIN | OTHER | 500027765 | 01 |   | MEDICARE RR | OTHER |