Provider Demographics
NPI:1841550845
Name:GONDER, LORI
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:GONDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:
Other - Last Name:BOER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:PO BOX 106
Mailing Address - Street 2:WOODLAND
Mailing Address - City:WOODLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98674-0101
Mailing Address - Country:US
Mailing Address - Phone:360-910-6515
Mailing Address - Fax:
Practice Address - Street 1:566 GOERIG ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:WA
Practice Address - Zip Code:98674-9442
Practice Address - Country:US
Practice Address - Phone:360-910-6515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA19129174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist