Provider Demographics
NPI:1134412745
Name:LORN, SOPHANARY (LMP)
Entity type:Individual
Prefix:MS
First Name:SOPHANARY
Middle Name:
Last Name:LORN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-3568
Mailing Address - Country:US
Mailing Address - Phone:512-922-3138
Mailing Address - Fax:
Practice Address - Street 1:1551 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-3568
Practice Address - Country:US
Practice Address - Phone:512-922-3138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAND623175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath