Basic Information
| Provider Information | |||||||||
| NPI: | 1306897863 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOLLASCH | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | 9376194342 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 MERCY DR | ||||||||
| Address2: | |||||||||
| City: | COUNCIL BLUFFS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515033128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123285230 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 06/16/2008 | ||||||||
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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 | A111561 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 236904 | 01 | IA | MIDLAND CHOICE FOR IOWA | OTHER | 38588 | 01 | IA | BCBSNE FOR IOWA | OTHER | P00201286 | 01 | IA | RRMEDICARE FOR IOWA | OTHER | 0458653 | 05 | IA | MEDICAID | 100251147-00 | 05 | NE | MEDICAID | 37715 | 01 | IA | WELLMARK FOR IOWA | OTHER |