Provider Demographics
NPI:1891897724
Name:BROECKER, LORI A (MSN, RN, CNP)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:A
Last Name:BROECKER
Suffix:
Gender:F
Credentials:MSN, RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 W UNIVERSITY DR STE 425
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1897
Mailing Address - Country:US
Mailing Address - Phone:248-650-5861
Mailing Address - Fax:248-650-5865
Practice Address - Street 1:1135 W UNIVERSITY DR STE 425
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1897
Practice Address - Country:US
Practice Address - Phone:248-650-5861
Practice Address - Fax:248-650-5865
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704163372363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM5862003Medicare ID - Type Unspecified
MI0M15890009Medicare PIN