Provider Demographics
NPI:1164676854
Name:UNTERBRINK, LORI DAWN (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:DAWN
Last Name:UNTERBRINK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:LORI
Other - Middle Name:DAWN
Other - Last Name:WADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:512 GENERAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT WRIGHT
Mailing Address - State:KY
Mailing Address - Zip Code:41011
Mailing Address - Country:US
Mailing Address - Phone:859-757-6530
Mailing Address - Fax:
Practice Address - Street 1:630 EATON AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013
Practice Address - Country:US
Practice Address - Phone:513-867-2101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-09
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1090581367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200929950Medicaid
KY7100070730Medicaid
000000596708OtherANTHEM
OH2939931Medicaid
$$$$$$$$$00OtherBUREAU OF WORKERS COMP
611077369-$$$$$$$$$OtherHEALTHNET
0918156Medicare PIN
P00674835Medicare PIN