Provider Demographics
NPI:1992234306
Name:BRODY, LORIN GENE (FNP-BC)
Entity type:Individual
Prefix:MS
First Name:LORIN
Middle Name:GENE
Last Name:BRODY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:LORIN
Other - Middle Name:G
Other - Last Name:FLISK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:145 S VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7226
Mailing Address - Country:US
Mailing Address - Phone:815-444-4999
Mailing Address - Fax:815-986-1363
Practice Address - Street 1:145 S VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7226
Practice Address - Country:US
Practice Address - Phone:815-444-4999
Practice Address - Fax:815-986-1363
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277001022363LF0000X, 363LP0808X
IL209015534363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty