Provider Demographics
NPI:1407451800
Name:ELLIS, LORI (LPN)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-4700
Mailing Address - Country:US
Mailing Address - Phone:504-517-2873
Mailing Address - Fax:
Practice Address - Street 1:301 W AIRLINE HWY STE 201
Practice Address - Street 2:
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-3823
Practice Address - Country:US
Practice Address - Phone:504-517-2873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2021-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA280026164W00000X
331L00000X, 246RM2200X, 246RM2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No331L00000XSuppliersBlood Bank
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5043194950Medicaid