Provider Demographics
NPI:1386661726
Name:LERDAHL, ANN MARIE
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:LERDAHL
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 1:575 S 70TH ST STE 305
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2471
Mailing Address - Country:US
Mailing Address - Phone:402-434-5600
Mailing Address - Fax:402-434-5601
Practice Address - Street 1:555 S 70TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-2462
Practice Address - Country:US
Practice Address - Phone:402-434-5600
Practice Address - Fax:402-434-5601
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE100200367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47060018715Medicaid
NE47060018715Medicaid