Provider Demographics
NPI:1174935910
Name:PROVENCHER, LORRAINE MYERS (MD)
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:MYERS
Last Name:PROVENCHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LORRAINE
Other - Middle Name:AMBER
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4909 S 118TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-2213
Mailing Address - Country:US
Mailing Address - Phone:402-506-9970
Mailing Address - Fax:605-371-7199
Practice Address - Street 1:4909 S 118TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-2213
Practice Address - Country:US
Practice Address - Phone:402-506-9970
Practice Address - Fax:605-371-7199
Is Sole Proprietor?:No
Enumeration Date:2014-05-28
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE35854207W00000X
MI4301114340207W00000X
OH35135901207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology