Provider Demographics
NPI:1982252631
Name:FORMELLA, LORRIE ANN
Entity Type:Individual
Prefix:
First Name:LORRIE
Middle Name:ANN
Last Name:FORMELLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N7590 LOWER CLIFF RD
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:54169-9704
Mailing Address - Country:US
Mailing Address - Phone:920-750-1845
Mailing Address - Fax:
Practice Address - Street 1:604 N RICHMOND ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-4659
Practice Address - Country:US
Practice Address - Phone:920-750-1845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer