Provider Demographics
NPI:1548742521
Name:GANNI, LORI ANN (MT0020842)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:GANNI
Suffix:
Gender:F
Credentials:MT0020842
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1933 CARTERET AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3247
Mailing Address - Country:US
Mailing Address - Phone:303-910-8634
Mailing Address - Fax:
Practice Address - Street 1:1303 FORTINO BLVD STE C
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2032
Practice Address - Country:US
Practice Address - Phone:303-910-8634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0024842225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist