Provider Demographics
NPI:1851835045
Name:GRESOWSKI, LORI JO
Entity Type:Individual
Prefix:
First Name:LORI JO
Middle Name:
Last Name:GRESOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3175 FIRESTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-2951
Mailing Address - Country:US
Mailing Address - Phone:949-929-4165
Mailing Address - Fax:323-923-5460
Practice Address - Street 1:3175 FIRESTONE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-2951
Practice Address - Country:US
Practice Address - Phone:949-929-4165
Practice Address - Fax:323-923-5460
Is Sole Proprietor?:No
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP12408364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00NP12408Medicaid