=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104159862
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LORI A PROVENZANO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2009
-----------------------------------------------------
Last Update Date | 01/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5105 SOM CENTER RD
-----------------------------------------------------
City | WILLOUGHBY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44094-4203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-975-4646
-----------------------------------------------------
Fax | 440-975-4607
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6247 GATEWOOD DR
-----------------------------------------------------
City | MENTOR
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44060-2147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | RN264203
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------