Provider Demographics
NPI:1801278528
Name:OSTERMAN FRUCTUOSO, LORI (LPT)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:OSTERMAN FRUCTUOSO
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2137 E DUELL ST
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-4612
Mailing Address - Country:US
Mailing Address - Phone:909-247-7734
Mailing Address - Fax:
Practice Address - Street 1:2137 E DUELL ST
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-4612
Practice Address - Country:US
Practice Address - Phone:909-247-7734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-19
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT38159167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician