Provider Demographics
NPI:1003281940
Name:BRAVENBOER, LORI (FNP)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:
Last Name:BRAVENBOER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 HIDDEN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:NJ
Mailing Address - Zip Code:07462-3153
Mailing Address - Country:US
Mailing Address - Phone:973-214-2334
Mailing Address - Fax:
Practice Address - Street 1:181 HIGH ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860-1020
Practice Address - Country:US
Practice Address - Phone:973-383-9898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00603500363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily