Provider Demographics
NPI:1053780049
Name:GONZALES, LORIE (LPN)
Entity type:Individual
Prefix:
First Name:LORIE
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:FORT COBB
Mailing Address - State:OK
Mailing Address - Zip Code:73038-0307
Mailing Address - Country:US
Mailing Address - Phone:405-668-2585
Mailing Address - Fax:
Practice Address - Street 1:1515 NE LAWRIE TATUM RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-3002
Practice Address - Country:US
Practice Address - Phone:580-354-5391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-19
Last Update Date:2015-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0034191164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse