Provider Demographics
NPI:1720395783
Name:LAKE NORMAN PAIN AND WEIGHT MANAGEMENT, LLC
Entity Type:Organization
Organization Name:LAKE NORMAN PAIN AND WEIGHT MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISSY
Authorized Official - Middle Name:GAYLE
Authorized Official - Last Name:FOHR
Authorized Official - Suffix:
Authorized Official - Credentials:NPC
Authorized Official - Phone:336-414-1164
Mailing Address - Street 1:378 WILLIAMSON RD STE 204
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-5917
Mailing Address - Country:US
Mailing Address - Phone:704-662-0009
Mailing Address - Fax:704-360-2335
Practice Address - Street 1:378 WILLIAMSON RD STE 204
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5917
Practice Address - Country:US
Practice Address - Phone:704-662-0009
Practice Address - Fax:704-360-2335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-10
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004119363LA2200X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7004603Medicaid