Provider Demographics
NPI:1639726110
Name:CARLSON, LORI ANN (OWNER)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-1271
Mailing Address - Country:US
Mailing Address - Phone:763-689-8984
Mailing Address - Fax:
Practice Address - Street 1:626 MAIN ST N
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-1271
Practice Address - Country:US
Practice Address - Phone:763-689-8984
Practice Address - Fax:763-689-1170
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA6839980003747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant