Provider Demographics
NPI:1528443298
Name:GRISHAM, LORI (MT)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:
Last Name:GRISHAM
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 OAKWOOD LN
Mailing Address - Street 2:
Mailing Address - City:HICKORY CREEK
Mailing Address - State:TX
Mailing Address - Zip Code:75065-7673
Mailing Address - Country:US
Mailing Address - Phone:940-453-1597
Mailing Address - Fax:
Practice Address - Street 1:751 HEBRON PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-5055
Practice Address - Country:US
Practice Address - Phone:940-453-1597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK69721246QL0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QL0900XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyLaboratory Management