Provider Demographics
NPI:1538742788
Name:DOUGLASS, LORI MAE (NP, MS, CCM)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:MAE
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:NP, MS, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MILLER AVE STE 331
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-1903
Mailing Address - Country:US
Mailing Address - Phone:415-381-3133
Mailing Address - Fax:415-381-3131
Practice Address - Street 1:35 MILLER AVE STE 331
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-1903
Practice Address - Country:US
Practice Address - Phone:415-381-3133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA381935363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health