Provider Demographics
NPI:1093374704
Name:PIERSON, LORRIE M
Entity Type:Individual
Prefix:
First Name:LORRIE
Middle Name:M
Last Name:PIERSON
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:PO BOX 635
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-0635
Mailing Address - Country:US
Mailing Address - Phone:928-640-0245
Mailing Address - Fax:928-484-2000
Practice Address - Street 1:680 HAUL RD
Practice Address - Street 2:SUITE B
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040-8604
Practice Address - Country:US
Practice Address - Phone:928-640-0245
Practice Address - Fax:928-484-2000
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ232248253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ232248Medicaid