Healthcare Provider Details

I. General information

NPI: 1851812747
Provider Name (Legal Business Name): QIAORONG LIU AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1716 HARTFORD ST
LAFAYETTE IN
47904-2138
US

IV. Provider business mailing address

1716 HARTFORD ST
LAFAYETTE IN
47904-2138
US

V. Phone/Fax

Practice location:
  • Phone: 765-742-1567
  • Fax: 765-742-2750
Mailing address:
  • Phone: 765-742-1567
  • Fax: 765-429-2700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number28225212A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number28225212A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: