Provider Demographics
NPI:1598916520
Name:GUNDBERG, LORI BETH (LPN)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:BETH
Last Name:GUNDBERG
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:PO BOX 1428
Mailing Address - Street 2:5040 RT. 213
Mailing Address - City:OLIVEBRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12461-0428
Mailing Address - Country:US
Mailing Address - Phone:845-633-6232
Mailing Address - Fax:
Practice Address - Street 1:5040 ROUTE 213
Practice Address - Street 2:
Practice Address - City:OLIVEBRIDGE
Practice Address - State:NY
Practice Address - Zip Code:12461-5614
Practice Address - Country:US
Practice Address - Phone:845-633-6232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY267976164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse