Provider Demographics
NPI:1164928404
Name:FISSENDEN, LORRIE BARNETT (MSOM, LAC)
Entity Type:Individual
Prefix:
First Name:LORRIE
Middle Name:BARNETT
Last Name:FISSENDEN
Suffix:
Gender:F
Credentials:MSOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 HILL RD STE G
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-4338
Mailing Address - Country:US
Mailing Address - Phone:415-761-1440
Mailing Address - Fax:
Practice Address - Street 1:1615 HILL RD STE G
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-4338
Practice Address - Country:US
Practice Address - Phone:415-761-1440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU.0002388171100000X
CA19974171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist