Provider Demographics
NPI:1265262372
Name:WISOTZKEY, LORI ETTA (CCHW, CRS,CFRS)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:ETTA
Last Name:WISOTZKEY
Suffix:
Gender:F
Credentials:CCHW, CRS,CFRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5375 BOARD RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT WOLF
Mailing Address - State:PA
Mailing Address - Zip Code:17347-9565
Mailing Address - Country:US
Mailing Address - Phone:717-660-3571
Mailing Address - Fax:
Practice Address - Street 1:5375 BOARD RD
Practice Address - Street 2:
Practice Address - City:MOUNT WOLF
Practice Address - State:PA
Practice Address - Zip Code:17347-9565
Practice Address - Country:US
Practice Address - Phone:717-660-3571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-05
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA20584175T00000X
374J00000X
PA50284172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
No374J00000XNursing Service Related ProvidersDoula