Provider Demographics
NPI:1811084098
Name:SIDE, LORRAINE P (MA MS RN CS APRN)
Entity type:Individual
Prefix:MRS
First Name:LORRAINE
Middle Name:P
Last Name:SIDE
Suffix:
Gender:F
Credentials:MA MS RN CS APRN
Other - Prefix:
Other - First Name:LORRAINE
Other - Middle Name:P
Other - Last Name:COSTELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA MS RN CS APRN
Mailing Address - Street 1:2151 DEEP CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PERKIOMENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18074
Mailing Address - Country:US
Mailing Address - Phone:215-541-9089
Mailing Address - Fax:215-679-3144
Practice Address - Street 1:2151 DEEP CREEK RD
Practice Address - Street 2:
Practice Address - City:PERKIOMENVILLE
Practice Address - State:PA
Practice Address - Zip Code:18074
Practice Address - Country:US
Practice Address - Phone:215-541-9089
Practice Address - Fax:215-679-3144
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN248822L364S00000X
101YP2500X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
0005815320OtherAETNA
0492730000OtherKEYSTONE & AMERIHEALTH
0492730000OtherKEYSTONE & AMERIHEALTH