Provider Demographics
NPI:1750579652
Name:LODGE, ANN (RN)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:LODGE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 DOWNEY DR
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-6133
Mailing Address - Country:US
Mailing Address - Phone:610-209-3706
Mailing Address - Fax:
Practice Address - Street 1:53 DOWNEY DRIVE
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126
Practice Address - Country:US
Practice Address - Phone:610-209-3706
Practice Address - Fax:610-209-3706
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-05
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY587237163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02882328Medicaid