Provider Demographics
NPI:1790196244
Name:LANDRETH, LORI (CPNP-PC)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:
Last Name:LANDRETH
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 HAWTHORN RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-1028
Mailing Address - Country:US
Mailing Address - Phone:618-548-4590
Mailing Address - Fax:618-548-8275
Practice Address - Street 1:1275 HAWTHORN RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-1028
Practice Address - Country:US
Practice Address - Phone:618-548-4590
Practice Address - Fax:618-548-8275
Is Sole Proprietor?:No
Enumeration Date:2014-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.011381363LP0200X
FLARNP9382830363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHU297ZOtherMEDICARE PTAN
FLHU297ZOtherMEDICARE PTAN