Provider Demographics
NPI:1891006201
Name:MOONEY, LORI GROSS (CRNP-PMH)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:GROSS
Last Name:MOONEY
Suffix:
Gender:F
Credentials:CRNP-PMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 EASTERN BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ESSEX
Mailing Address - State:MD
Mailing Address - Zip Code:21221-6738
Mailing Address - Country:US
Mailing Address - Phone:410-391-8240
Mailing Address - Fax:443-460-0293
Practice Address - Street 1:532 EASTERN BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:ESSEX
Practice Address - State:MD
Practice Address - Zip Code:21221-6738
Practice Address - Country:US
Practice Address - Phone:410-391-8240
Practice Address - Fax:443-460-0293
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR169704363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD332518100Medicaid