Provider Demographics
NPI:1376626176
Name:WIGLEY, LORI JEANNE (PT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:JEANNE
Last Name:WIGLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:JEANNE
Other - Last Name:HIRSCHKORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15654 THORNBUSH RD
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:CA
Mailing Address - Zip Code:92065-4823
Mailing Address - Country:US
Mailing Address - Phone:541-310-0636
Mailing Address - Fax:
Practice Address - Street 1:1338 MAIN ST
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:CA
Practice Address - Zip Code:92065-2127
Practice Address - Country:US
Practice Address - Phone:760-789-1400
Practice Address - Fax:760-789-1401
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3341225100000X
WAPT00010169225100000X
CA294206225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022414003OtherREGENCE BLUECROSS/BLUESHE