Provider Demographics
NPI:1225361470
Name:CARLSON, LORI (FNPC)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:FNPC
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 20970
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7020
Mailing Address - Country:US
Mailing Address - Phone:307-633-7444
Mailing Address - Fax:307-634-5627
Practice Address - Street 1:800 E 20TH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3885
Practice Address - Country:US
Practice Address - Phone:307-633-7444
Practice Address - Fax:307-634-5627
Is Sole Proprietor?:No
Enumeration Date:2009-09-04
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY15471.1013363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY12253614701Medicaid