Provider Demographics
NPI:1376656744
Name:ANDERSON, LORI R (CRNA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 HARLEM RD
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-2754
Mailing Address - Country:US
Mailing Address - Phone:815-877-4848
Mailing Address - Fax:815-654-5342
Practice Address - Street 1:2202 HARLEM RD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-2754
Practice Address - Country:US
Practice Address - Phone:815-877-4848
Practice Address - Fax:815-654-5342
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041191136163W00000X
WI100815-030163W00000X
IL209-000340367500000X
IL209000340367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
430075651OtherRAILROAD MEDICARE
S45384Medicare UPIN
IL593490/L93280Medicare ID - Type Unspecified