Provider Demographics
NPI:1235762097
Name:RETTERATH, LORI ELLEN
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ELLEN
Last Name:RETTERATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 NE 5TH CT
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-1269
Mailing Address - Country:US
Mailing Address - Phone:954-529-9186
Mailing Address - Fax:
Practice Address - Street 1:1401 NE 5TH CT
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-1269
Practice Address - Country:US
Practice Address - Phone:954-529-9186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11006195363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner