Provider Demographics
NPI:1528657210
Name:GANTON, LORI ELAINE
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:ELAINE
Last Name:GANTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7155 W S AVE
Mailing Address - Street 2:
Mailing Address - City:SCHOOLCRAFT
Mailing Address - State:MI
Mailing Address - Zip Code:49087-8433
Mailing Address - Country:US
Mailing Address - Phone:269-254-7045
Mailing Address - Fax:
Practice Address - Street 1:7155 W S AVE
Practice Address - Street 2:
Practice Address - City:SCHOOLCRAFT
Practice Address - State:MI
Practice Address - Zip Code:49087-8433
Practice Address - Country:US
Practice Address - Phone:269-254-7045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-16
Last Update Date:2021-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704237873363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner