Provider Demographics
NPI:1972591287
Name:WALDERA, LORI (CNM, F N P)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:WALDERA
Suffix:
Gender:F
Credentials:CNM, F N P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CENTURY AVE
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:MN
Mailing Address - Zip Code:55350
Mailing Address - Country:US
Mailing Address - Phone:320-587-2020
Mailing Address - Fax:320-484-4686
Practice Address - Street 1:3 CENTURY AVE
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350
Practice Address - Country:US
Practice Address - Phone:320-587-2020
Practice Address - Fax:320-484-4686
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP3348363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN262308100Medicaid
MN262308100Medicaid
MNS28445Medicare UPIN
MN500003945Medicare PIN