Provider Demographics
NPI:1104495910
Name:LUNDBERG, LORI LEI LIDWIN (RN, MNE)
Entity type:Individual
Prefix:
First Name:LORI LEI
Middle Name:LIDWIN
Last Name:LUNDBERG
Suffix:
Gender:F
Credentials:RN, MNE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95-1115 KOOLANI DR APT 202
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-5914
Mailing Address - Country:US
Mailing Address - Phone:808-394-0678
Mailing Address - Fax:
Practice Address - Street 1:480 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:JBPHH
Practice Address - State:HI
Practice Address - Zip Code:96860-4908
Practice Address - Country:US
Practice Address - Phone:808-471-3026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA991229237163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management