Provider Demographics
NPI:1235110263
Name:PONDER, LORI (CRNP)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:PONDER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 RIVERBEND DR SW
Mailing Address - Street 2:STE 100
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-6065
Mailing Address - Country:US
Mailing Address - Phone:706-291-0884
Mailing Address - Fax:706-378-8267
Practice Address - Street 1:15 RIVERBEND DR SW
Practice Address - Street 2:STE 100
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-6065
Practice Address - Country:US
Practice Address - Phone:706-291-0884
Practice Address - Fax:706-378-8267
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-089350363L00000X
GARN147727363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA205983747AMedicaid
ALQ48386Medicare UPIN
AL051528447Medicare ID - Type Unspecified
GA511I500537Medicare UPIN