Healthcare Provider Details

I. General information

NPI: 1427461540
Provider Name (Legal Business Name): LORRI JO MOSTAD APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 E STATE ST
ROCKFORD IL
61104-2315
US

IV. Provider business mailing address

PO BOX 1567
ROCKFORD IL
61110-0067
US

V. Phone/Fax

Practice location:
  • Phone: 815-489-4123
  • Fax: 815-967-5481
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number121866
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number041419609
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209011678
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: