Provider Demographics
NPI:1942830690
Name:ICKES, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:ICKES
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 1:110 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:NELIGH
Mailing Address - State:NE
Mailing Address - Zip Code:68756-1464
Mailing Address - Country:US
Mailing Address - Phone:402-887-5041
Mailing Address - Fax:866-737-5735
Practice Address - Street 1:110 W 3RD ST
Practice Address - Street 2:
Practice Address - City:NELIGH
Practice Address - State:NE
Practice Address - Zip Code:68756-1464
Practice Address - Country:US
Practice Address - Phone:402-887-5041
Practice Address - Fax:866-737-5735
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE66019163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice