Provider Demographics
NPI:1073719639
Name:LORENZ, NICOLE DANIELLE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DANIELLE
Last Name:LORENZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 5TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:MT
Mailing Address - Zip Code:59230-2600
Mailing Address - Country:US
Mailing Address - Phone:406-228-3536
Mailing Address - Fax:406-228-3537
Practice Address - Street 1:221 5TH AVE S
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:MT
Practice Address - Zip Code:59230-2600
Practice Address - Country:US
Practice Address - Phone:406-228-3536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD156731208600000X
MT76921208600000X
MI4301090377208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery