Provider Demographics
NPI:1801090865
Name:WINGATE, LORI JO (APRN-BC)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:JO
Last Name:WINGATE
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4222 WENDOVER AVE
Mailing Address - Street 2:400
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-5945
Mailing Address - Country:US
Mailing Address - Phone:432-367-8080
Mailing Address - Fax:432-366-8443
Practice Address - Street 1:4222 WENDOVER AVE
Practice Address - Street 2:400
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-5945
Practice Address - Country:US
Practice Address - Phone:432-367-8080
Practice Address - Fax:432-366-8443
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX236283363LF0000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX236283OtherSTATE LICENSE