Provider Demographics
NPI:1063039345
Name:WELLER, LORI M (CNP)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:M
Last Name:WELLER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1148 BROADWAY STE 100
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-3518
Mailing Address - Country:US
Mailing Address - Phone:253-589-7030
Mailing Address - Fax:
Practice Address - Street 1:1148 BROADWAY STE 100
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-3518
Practice Address - Country:US
Practice Address - Phone:253-589-7030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61083965363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner