Provider Demographics
NPI:1558903914
Name:IVERSEN, LORI A (CNP)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:IVERSEN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 46
Mailing Address - Street 2:
Mailing Address - City:MURDO
Mailing Address - State:SD
Mailing Address - Zip Code:57559-0046
Mailing Address - Country:US
Mailing Address - Phone:605-530-0164
Mailing Address - Fax:
Practice Address - Street 1:609 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:MURDO
Practice Address - State:SD
Practice Address - Zip Code:57559-4100
Practice Address - Country:US
Practice Address - Phone:605-669-2121
Practice Address - Fax:605-669-3301
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001654363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner