Provider Demographics
NPI:1962742072
Name:REISERT, JOANNA LYNN (NP)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:LYNN
Last Name:REISERT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1100 REID PKWY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-827-8064
Mailing Address - Fax:765-825-6999
Practice Address - Street 1:2025 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-2971
Practice Address - Country:US
Practice Address - Phone:765-827-8064
Practice Address - Fax:765-825-6999
Is Sole Proprietor?:No
Enumeration Date:2013-02-26
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004348A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN28156776AOtherRN LIC