Provider Demographics
NPI:1174713820
Name:LOBODZINSKI, STACY A (NP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:A
Last Name:LOBODZINSKI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:ER B412
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-962-8880
Practice Address - Fax:317-962-7086
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001400363LF0000X
IN71001400A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001414272OtherANTHEM PTAN
IN000000668467OtherANTHEM PTAN
IN000001067786OtherANTHEM PTAN
IN000001258280OtherANTHEM PTAN
IN000001314774OtherANTHEM PTAN
IN200880160Medicaid