Provider Demographics
NPI:1134560824
Name:OUR LADY OF LOURDES
Entity type:Organization
Organization Name:OUR LADY OF LOURDES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:M
Authorized Official - Last Name:LANCE
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:856-912-6397
Mailing Address - Street 1:1600 HADDON AVE
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-3101
Mailing Address - Country:US
Mailing Address - Phone:856-757-3500
Mailing Address - Fax:
Practice Address - Street 1:1600 HADDON AVE
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-3101
Practice Address - Country:US
Practice Address - Phone:856-757-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00311500282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital