Provider Demographics
NPI:1265432330
Name:BOOMS, LORI ANN (ANP)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:BOOMS
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ROLAND ST
Mailing Address - Street 2:
Mailing Address - City:MC BAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49657-9683
Mailing Address - Country:US
Mailing Address - Phone:231-825-8101
Mailing Address - Fax:231-825-8104
Practice Address - Street 1:100 N ROLAND ST
Practice Address - Street 2:
Practice Address - City:MC BAIN
Practice Address - State:MI
Practice Address - Zip Code:49657-9683
Practice Address - Country:US
Practice Address - Phone:231-825-8101
Practice Address - Fax:231-825-8104
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704168055363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI238635Medicare Oscar/Certification