Provider Demographics
NPI:1104111889
Name:ETENBURN, LORRIE LEE (CST/CFA)
Entity type:Individual
Prefix:
First Name:LORRIE
Middle Name:LEE
Last Name:ETENBURN
Suffix:
Gender:F
Credentials:CST/CFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:976 AGATE CT
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-3224
Mailing Address - Country:US
Mailing Address - Phone:970-812-6975
Mailing Address - Fax:
Practice Address - Street 1:976 AGATE CT
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-3224
Practice Address - Country:US
Practice Address - Phone:970-812-6975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant