Basic Information
| Provider Information | |||||||||
| NPI: | 1043256183 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | LOREA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 N NILES AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466171924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471610 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 I ST | ||||||||
| Address2: | |||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463505533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193241700 | ||||||||
| FaxNumber: | 2193241710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 07/18/2016 | ||||||||
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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 | 363L00000X | 71001622A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 200527180 | 05 | IN | MEDICAID | 000000742787 | 01 | IN | BCBS BMG LAPORTE | OTHER | 100092150A | 05 | IN | MEDICAID | P01049360 | 01 | IN | RR MEDICARE | OTHER |