Provider Demographics
NPI:1235521378
Name:CARLSON, LORI (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3270 W BIG BEAVER RD STE 400
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-2901
Mailing Address - Country:US
Mailing Address - Phone:248-816-2558
Mailing Address - Fax:248-816-2801
Practice Address - Street 1:3270 W BIG BEAVER RD STE 400
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-2901
Practice Address - Country:US
Practice Address - Phone:248-816-2558
Practice Address - Fax:248-816-2801
Is Sole Proprietor?:No
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704206655364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics