Provider Demographics
NPI:1568667491
Name:VISSER, LORI MUNDY (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:MUNDY
Last Name:VISSER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 RAES CREEK DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-1919
Mailing Address - Country:US
Mailing Address - Phone:864-335-8757
Mailing Address - Fax:
Practice Address - Street 1:1 SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3955
Practice Address - Country:US
Practice Address - Phone:864-255-1073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2630367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered