Provider Demographics
NPI:1174140909
Name:DENNIS, LOLA (PA-C)
Entity type:Individual
Prefix:
First Name:LOLA
Middle Name:
Last Name:DENNIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-983-3293
Mailing Address - Fax:
Practice Address - Street 1:109 E WASHINGTON JACKSON RD STE B
Practice Address - Street 2:
Practice Address - City:EATON
Practice Address - State:OH
Practice Address - Zip Code:45320-9793
Practice Address - Country:US
Practice Address - Phone:937-456-2155
Practice Address - Fax:937-456-2155
Is Sole Proprietor?:No
Enumeration Date:2020-06-27
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003214A363A00000X
OH50.006536363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant