Provider Demographics
NPI:1730100967
Name:MARMON, LORI ANN (PT)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:ANN
Last Name:MARMON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:LORI
Other - Middle Name:ANN
Other - Last Name:WILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4645 BELPAR ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3602
Mailing Address - Country:US
Mailing Address - Phone:330-493-4210
Mailing Address - Fax:330-493-4744
Practice Address - Street 1:6046 WHIPPLE AVE NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7616
Practice Address - Country:US
Practice Address - Phone:330-494-1912
Practice Address - Fax:330-494-1915
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT 008098225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000134713OtherANTHEM BC/BS