Basic Information
| Provider Information | |||||||||
| NPI: | 1568405942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEIS | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WARNER | ||||||||
| OtherFirstName: | LORI | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 950296 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028930220 | ||||||||
| FaxNumber: | 5028930563 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 KRESGE WAY | ||||||||
| Address2: | #207 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028930220 | ||||||||
| FaxNumber: | 5028930563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 01/26/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 4164P | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 363L00000X | 4164P | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 78012168 | 05 | KY | MEDICAID | 4164P | 01 | KY | LICENSE | OTHER |