Healthcare Provider Details

I. General information

NPI: 1760315824
Provider Name (Legal Business Name): LISEDA SERGILE
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2889 HEPBURN CIR
BROWNSBURG IN
46112-5703
US

IV. Provider business mailing address

2889 HEPBURN CIR
BROWNSBURG IN
46112-5703
US

V. Phone/Fax

Practice location:
  • Phone: 765-485-1306
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28276951A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71018501A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: