Provider Demographics
NPI:1588108559
Name:NETTLES, LORI
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:NETTLES
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 1:106 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:CRESSONA
Mailing Address - State:PA
Mailing Address - Zip Code:17929-1044
Mailing Address - Country:US
Mailing Address - Phone:570-294-4386
Mailing Address - Fax:
Practice Address - Street 1:106 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:CRESSONA
Practice Address - State:PA
Practice Address - Zip Code:17929-1044
Practice Address - Country:US
Practice Address - Phone:570-294-4386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-11
Last Update Date:2016-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP007211174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist