Provider Demographics
NPI:1669142451
Name:RUST, LORI
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:RUST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:861 CLAREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:SANGER
Mailing Address - State:CA
Mailing Address - Zip Code:93657-8738
Mailing Address - Country:US
Mailing Address - Phone:209-815-0032
Mailing Address - Fax:
Practice Address - Street 1:861 CLAREMONT AVE
Practice Address - Street 2:
Practice Address - City:SANGER
Practice Address - State:CA
Practice Address - Zip Code:93657-8738
Practice Address - Country:US
Practice Address - Phone:209-815-0032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA465198163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice