Basic Information
| Provider Information | |||||||||
| NPI: | 1124682448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAGE | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | RN, CCM | ||||||||
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| Mailing Information | |||||||||
| Address1: | BUILDING 11582 | ||||||||
| Address2: | 17TH & C STREET | ||||||||
| City: | JOINT BASE LEWIS-MCCHORD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539667633 | ||||||||
| FaxNumber: | 2539672639 | ||||||||
| Practice Location | |||||||||
| Address1: | BUILDING 11582 | ||||||||
| Address2: | 17TH & C STREET | ||||||||
| City: | JOINT BASE LEWIS-MCCHORD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539667633 | ||||||||
| FaxNumber: | 2539672639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2019 | ||||||||
| LastUpdateDate: | 04/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0400X | 00086828 | WA | Y | Nursing Service Providers | Registered Nurse | Case Management |
No ID Information.