Provider Demographics
NPI:1356832877
Name:HEGINBOTHAM, LORI CATHERINE
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:CATHERINE
Last Name:HEGINBOTHAM
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 1:1025 OLIVIA WAY
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-4897
Mailing Address - Country:US
Mailing Address - Phone:252-337-4645
Mailing Address - Fax:
Practice Address - Street 1:1025 OLIVIA WAY
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-4897
Practice Address - Country:US
Practice Address - Phone:252-337-4645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3747P1801XMedicaid