Basic Information
| Provider Information | |||||||||
| NPI: | 1710041074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VEROSTICK | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TALLION | ||||||||
| OtherFirstName: | LORI | ||||||||
| OtherMiddleName: | A. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1086 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159054305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144108300 | ||||||||
| FaxNumber: | 8144108331 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 FRANKLIN ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159054330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8145349230 | ||||||||
| FaxNumber: | 8145349465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 06/05/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | MW010009 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 0018799940005 | 05 | PA | MEDICAID | 1370696 | 01 | PA | BC BS | OTHER |