Provider Demographics
NPI:1396058756
Name:BURBANK, LORI E (CRNA)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:E
Last Name:BURBANK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:E
Other - Last Name:BLOEMENDAAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4918
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32802-4918
Mailing Address - Country:US
Mailing Address - Phone:407-581-9180
Mailing Address - Fax:407-926-9173
Practice Address - Street 1:400 N MILLS AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5722
Practice Address - Country:US
Practice Address - Phone:407-581-9180
Practice Address - Fax:407-926-9173
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9202695367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG00H7OtherBCBS
XXX-XX-2771OtherCHAMPUS / TRICARE (SOUTH REGION)
FL0025946 00Medicaid
P00878821OtherRAILROAD MEDICARE
FL0025946 00Medicaid