Provider Demographics
NPI:1356714372
Name:MAZE, LORI TIFFANY
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:TIFFANY
Last Name:MAZE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:TIFFANY
Other - Last Name:GRADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:10006 CHESNEY DR
Mailing Address - Street 2:
Mailing Address - City:SPOTSYLVANIA
Mailing Address - State:VA
Mailing Address - Zip Code:22553-1776
Mailing Address - Country:US
Mailing Address - Phone:703-975-4774
Mailing Address - Fax:
Practice Address - Street 1:9500 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-3701
Practice Address - Country:US
Practice Address - Phone:703-975-4774
Practice Address - Fax:540-301-6195
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-12
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173056363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner