Provider Demographics
NPI:1740230531
Name:WIDDALL, LORRAINE KAY (CNS)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:KAY
Last Name:WIDDALL
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8317 CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1737
Mailing Address - Country:US
Mailing Address - Phone:219-513-2333
Mailing Address - Fax:219-513-2334
Practice Address - Street 1:8317 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1737
Practice Address - Country:US
Practice Address - Phone:219-513-2333
Practice Address - Fax:219-513-1127
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28087637A364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200473170Medicaid
IN200473170Medicaid
INQ18610Medicare UPIN
IN148530AAMedicare PIN