Provider Demographics
NPI:1992294003
Name:GUDAT, LORI MEINTS (NP)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:MEINTS
Last Name:GUDAT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3916 W CRESTRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-8958
Mailing Address - Country:US
Mailing Address - Phone:309-253-6433
Mailing Address - Fax:
Practice Address - Street 1:411 MAXINE DR
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-2495
Practice Address - Country:US
Practice Address - Phone:309-266-9757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017105363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily