Provider Demographics
NPI:1508372152
Name:PTAK, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:PTAK
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 1:11115 W. HIGHWAY 24
Mailing Address - Street 2:UNIT 2C
Mailing Address - City:DIVIDE
Mailing Address - State:CO
Mailing Address - Zip Code:80814
Mailing Address - Country:US
Mailing Address - Phone:719-687-6416
Mailing Address - Fax:719-687-6501
Practice Address - Street 1:11115 W HIGHWAY 24
Practice Address - Street 2:UNIT 2C
Practice Address - City:DIVIDE
Practice Address - State:CO
Practice Address - Zip Code:80814
Practice Address - Country:US
Practice Address - Phone:719-687-6416
Practice Address - Fax:719-687-6501
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.1641286163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04540548Medicaid