Provider Demographics
NPI:1376855650
Name:HEDGES, LOREL S (MS, ANP, BC, ACHPN)
Entity Type:Individual
Prefix:
First Name:LOREL
Middle Name:S
Last Name:HEDGES
Suffix:
Gender:F
Credentials:MS, ANP, BC, ACHPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 PRIVATEER LN
Mailing Address - Street 2:
Mailing Address - City:MT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-2574
Mailing Address - Country:US
Mailing Address - Phone:312-933-9138
Mailing Address - Fax:
Practice Address - Street 1:169 PRIVATEER LN
Practice Address - Street 2:
Practice Address - City:MT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-2574
Practice Address - Country:US
Practice Address - Phone:312-933-9138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-02
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20297363LA2200X
IL209001406364SX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No364SX0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ08786Medicare UPIN