Provider Demographics
NPI:1851517338
Name:PENROD, LORELEI (LPN, CHPLN)
Entity Type:Individual
Prefix:
First Name:LORELEI
Middle Name:
Last Name:PENROD
Suffix:
Gender:F
Credentials:LPN, CHPLN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3263 OCALA AVE NW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-2373
Mailing Address - Country:US
Mailing Address - Phone:330-837-8498
Mailing Address - Fax:
Practice Address - Street 1:2841 25TH ST NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44705-3669
Practice Address - Country:US
Practice Address - Phone:330-458-0780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN090083164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH106981839999Medicaid