Provider Demographics
NPI:1114988318
Name:CARLSON, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:CARLSON
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 1:17810 24TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-2108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 S 4TH ST
Practice Address - Street 2:DHFS, ROOM 510
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1335
Practice Address - Country:US
Practice Address - Phone:612-673-3548
Practice Address - Fax:612-673-3866
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN094598-7363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN12-03427OtherMEDICA
MN251343900Medicaid
MN9L584CAOtherBCBS
MNHP19846OtherHEALTH PARTNERS
MN923911015067OtherPREFERRED ONE
MN500003178Medicare ID - Type Unspecified
MNS47670Medicare UPIN