Provider Demographics
NPI:1396722559
Name:EDMONDS, LORI L (ARNP)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:L
Last Name:EDMONDS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:L
Other - Last Name:DEGRAFFENREID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:4130 DUTCHMANS LN
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4713
Mailing Address - Country:US
Mailing Address - Phone:502-897-1794
Mailing Address - Fax:502-238-1286
Practice Address - Street 1:4130 DUTCHMANS LN
Practice Address - Street 2:SUITE 300
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4713
Practice Address - Country:US
Practice Address - Phone:502-897-1794
Practice Address - Fax:502-238-1286
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004706363L00000X
IN71005529A363L00000X
IN71005529B363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201078540Medicaid
KY7100145280Medicaid
KY1277617Medicare PIN
IN1920015Medicare PIN
IN201078540Medicaid