Basic Information
Provider Information | |||||||||
NPI: | 1134288251 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLARK | ||||||||
FirstName: | LORI | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5520 | ||||||||
Address2: |   | ||||||||
City: | BETHLEHEM | ||||||||
State: | PA | ||||||||
PostalCode: | 180150520 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6109545810 | ||||||||
FaxNumber: | 6109545480 | ||||||||
Practice Location | |||||||||
Address1: | 801 OSTRUM ST | ||||||||
Address2: |   | ||||||||
City: | BETHLEHEM | ||||||||
State: | PA | ||||||||
PostalCode: | 180151000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6109545810 | ||||||||
FaxNumber: | 6109545480 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/06/2006 | ||||||||
LastUpdateDate: | 10/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/06/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN-507355-L | PA | N |   | Nursing Service Providers | Registered Nurse |   | 367500000X | 076891 | PA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 1580856 | 01 | PA | GATEWAY | OTHER | 1924485 | 01 | PA | FIRST PRIORITY | OTHER | 11802986 | 01 | PA | CAQH | OTHER | 104166 | 01 | PA | GEISINGER | OTHER | 50065227 | 01 | PA | CAPITAL ADVANTAGE | OTHER | 9696443 | 01 | PA | AETNA | OTHER | 1924485 | 01 | PA | HIGHMARK | OTHER | 1027796550001 | 05 | PA |   | MEDICAID | 2792759000 | 01 | PA | IBC | OTHER |