1124070958 NPI number — LORI A. CHANCELLOR CRNA

Table of content: LORI A. CHANCELLOR CRNA (NPI 1124070958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124070958 NPI number — LORI A. CHANCELLOR CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHANCELLOR
Provider First Name:
LORI
Provider Middle Name:
A.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WHITWORTH
Provider Other First Name:
LORI
Provider Other Middle Name:
C.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1124070958
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 E LAMAR BLVD.
Provider Second Line Business Mailing Address:
STE 400
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76006-7353
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-861-3994
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 E LAMAR BLVD
Provider Second Line Business Practice Location Address:
STE 400
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76006-7346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-861-3994
Provider Business Practice Location Address Fax Number:
682-227-6869
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  248515 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 177537101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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