1235507377 NPI number — LORI JEAN WAIN CRNP

Table of content: (NPI 1881849842)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235507377 NPI number — LORI JEAN WAIN CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAIN
Provider First Name:
LORI
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRYANT
Provider Other First Name:
LORI
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235507377
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 MOUNT NEBO PTE STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PITTSBURGH
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15237-1316
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-548-1090
Provider Business Mailing Address Fax Number:
125-483-1234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 MOUNT NEBO POINTE RD STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PITTSBURGH
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15237-1316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-548-1090
Provider Business Practice Location Address Fax Number:
412-548-3123
Provider Enumeration Date:
09/06/2015

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: 363LF0000X , with the licence number:  SP015293 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1032706840001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 13613611 . This is a "CAQH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".