Basic Information
| Provider Information | |||||||||
| NPI: | 1871857185 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOCKEY | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CMA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3251 W 9TH ST | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192342893 | ||||||||
| FaxNumber: | 3192340354 | ||||||||
| Practice Location | |||||||||
| Address1: | 3251 W 9TH ST | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192342893 | ||||||||
| FaxNumber: | 3192340354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2012 | ||||||||
| LastUpdateDate: | 07/02/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | 2426671 | IA | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
ID Information
| ID | Type | State | Issuer | Description | 0074435 | 05 | IA | MEDICAID |