Provider Demographics
NPI:1215257175
Name:BALJAK, ELIZABETH ANNE (CNP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:BALJAK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANNE
Other - Last Name:LACASCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:PO BOX 725
Mailing Address - Street 2:
Mailing Address - City:PATASKALA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-0725
Mailing Address - Country:US
Mailing Address - Phone:740-975-4278
Mailing Address - Fax:
Practice Address - Street 1:8535 REFUGEE RD
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-9625
Practice Address - Country:US
Practice Address - Phone:740-205-2007
Practice Address - Fax:877-384-2597
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.11381-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3075014Medicaid