Provider Demographics
NPI:1942076336
Name:WALLISER, LORI ANN (LPN)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:WALLISER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 ROSEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-5814
Mailing Address - Country:US
Mailing Address - Phone:405-541-3325
Mailing Address - Fax:
Practice Address - Street 1:8125 S WALKER AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-9417
Practice Address - Country:US
Practice Address - Phone:405-634-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0070819164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse