Provider Demographics
NPI:1619043692
Name:PENDER, LORIE A (CNM)
Entity Type:Individual
Prefix:MRS
First Name:LORIE
Middle Name:A
Last Name:PENDER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5874 SHAUN RD
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-1624
Mailing Address - Country:US
Mailing Address - Phone:248-737-5197
Mailing Address - Fax:248-737-5197
Practice Address - Street 1:5777 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-2267
Practice Address - Country:US
Practice Address - Phone:248-932-9223
Practice Address - Fax:248-932-8641
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL-313608163WL0100X
MI4704233617363LW0102X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000494119OtherANTHEM BCBS
IN200843290Medicaid