Provider Demographics
NPI:1851584361
Name:ALLEN, LORI HACKETT (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:HACKETT
Last Name:ALLEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:JO
Other - Last Name:HACKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 3686
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-0994
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1870 INDEPENDENCE SQ STE D
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-5155
Practice Address - Country:US
Practice Address - Phone:770-396-6190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN140976 CRNA261QA1903X
GARN140976367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA432CBJA70Medicare PIN