Healthcare Provider Details

I. General information

NPI: 1790196244
Provider Name (Legal Business Name): LORI LANDRETH CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2014
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 HAWTHORN RD
SALEM IL
62881-1028
US

IV. Provider business mailing address

1275 HAWTHORN RD
SALEM IL
62881-1028
US

V. Phone/Fax

Practice location:
  • Phone: 618-548-4590
  • Fax: 618-548-8275
Mailing address:
  • Phone: 618-548-4590
  • Fax: 618-548-8275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209.011381
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberARNP9382830
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: