Provider Demographics
NPI:1043842867
Name:NELLENBACK, LORIE ANN (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:LORIE
Middle Name:ANN
Last Name:NELLENBACK
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:WEEDSPORT
Mailing Address - State:NY
Mailing Address - Zip Code:13166-0421
Mailing Address - Country:US
Mailing Address - Phone:315-406-5161
Mailing Address - Fax:
Practice Address - Street 1:1330 COUNTY ROAD 132
Practice Address - Street 2:
Practice Address - City:OVID
Practice Address - State:NY
Practice Address - Zip Code:14521-9700
Practice Address - Country:US
Practice Address - Phone:315-835-6136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF402660-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health