Provider Demographics
NPI:1679840359
Name:MARUM, LORI RENE (ACNP)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:RENE
Last Name:MARUM
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 MARLAY DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90069-1620
Mailing Address - Country:US
Mailing Address - Phone:213-458-1775
Mailing Address - Fax:
Practice Address - Street 1:8635 W 3RD STREET
Practice Address - Street 2:SUITE 675 W
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048
Practice Address - Country:US
Practice Address - Phone:310-967-4379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-22
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20596363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN368912Medicaid
CAFY834ZMedicare PIN