Provider Demographics
NPI:1336618644
Name:DEFREESE, LORA D (CNM)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:D
Last Name:DEFREESE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1215 LAWN AVE STE 100
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2450
Practice Address - Country:US
Practice Address - Phone:574-293-2893
Practice Address - Fax:574-293-1298
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2023-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09000316A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300021977Medicaid