Provider Demographics
NPI:1295817054
Name:KNUTSTROM, LORI ANN (DPM)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:ANN
Last Name:KNUTSTROM
Suffix:
Gender:F
Credentials:DPM
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 985
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451
Mailing Address - Country:US
Mailing Address - Phone:815-325-5975
Mailing Address - Fax:
Practice Address - Street 1:912 W SEMINARY AVE
Practice Address - Street 2:
Practice Address - City:ONARGA
Practice Address - State:IL
Practice Address - Zip Code:60955-1401
Practice Address - Country:US
Practice Address - Phone:815-268-4840
Practice Address - Fax:815-268-4845
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004332213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT87109Medicare UPIN
IL906110Medicare PIN
IL906110Medicare ID - Type Unspecified