Provider Demographics
NPI:1952366122
Name:LEE, LORI A (OD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:LEE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:A
Other - Last Name:COLEMAN-LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:6261 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:NY
Mailing Address - Zip Code:14892-9458
Mailing Address - Country:US
Mailing Address - Phone:570-888-7248
Mailing Address - Fax:
Practice Address - Street 1:523 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:PA
Practice Address - Zip Code:18810-1619
Practice Address - Country:US
Practice Address - Phone:570-888-7248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002010152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018624500003Medicaid
PA0018624500003Medicaid
PA052378Medicare PIN