Provider Demographics
NPI:1023679040
Name:GRACE, LORI S (NP)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:S
Last Name:GRACE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2335 CHURCH ST STE E
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-2700
Mailing Address - Country:US
Mailing Address - Phone:225-570-2489
Mailing Address - Fax:225-570-2986
Practice Address - Street 1:6550 MAIN ST STE 3500
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-4092
Practice Address - Country:US
Practice Address - Phone:225-658-6780
Practice Address - Fax:225-658-6781
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP206404363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2506081Medicaid