Healthcare Provider Details

I. General information

NPI: 1720310170
Provider Name (Legal Business Name): LORRI M PETTERSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2010
Last Update Date: 02/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

863 NE HIDDEN VALLEY DR UNIT 1
BEND OR
97701-6575
US

IV. Provider business mailing address

863 NE HIDDEN VALLEY DR UNIT 1
BEND OR
97701-6575
US

V. Phone/Fax

Practice location:
  • Phone: 541-350-3945
  • Fax:
Mailing address:
  • Phone: 541-350-3945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number200941831
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number200830291
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: