Provider Demographics
NPI:1932570330
Name:CHARBONNEAU, LORI (NNP)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:CHARBONNEAU
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2513 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5325
Mailing Address - Country:US
Mailing Address - Phone:231-876-7476
Mailing Address - Fax:
Practice Address - Street 1:1105 SIXTH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2349
Practice Address - Country:US
Practice Address - Phone:231-935-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-12
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704118878363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal