Provider Demographics
NPI:1376505958
Name:FAY, LORI ANNE (DO)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:ANNE
Last Name:FAY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MS
Other - First Name:LORI
Other - Middle Name:ANNE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3917 WEST ROAD
Mailing Address - Street 2:SUITE 150 LAMCC
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544
Mailing Address - Country:US
Mailing Address - Phone:505-662-4351
Mailing Address - Fax:505-662-2932
Practice Address - Street 1:3917 WEST ROAD
Practice Address - Street 2:SUITE 150 LAMCC
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544
Practice Address - Country:US
Practice Address - Phone:505-662-4351
Practice Address - Fax:505-662-2932
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR43734207Q00000X
NMT501207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM51770377Medicaid
NM51770377Medicaid