Provider Demographics
NPI:1073102356
Name:COSTNER, LORIE OWENS
Entity Type:Individual
Prefix:
First Name:LORIE
Middle Name:OWENS
Last Name:COSTNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 25TH AVENUE DR NE
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-9677
Mailing Address - Country:US
Mailing Address - Phone:828-322-4453
Mailing Address - Fax:828-324-9295
Practice Address - Street 1:1455 25TH AVENUE DR NE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-9677
Practice Address - Country:US
Practice Address - Phone:828-322-4453
Practice Address - Fax:828-324-9295
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC121531163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1295729747Medicaid