Provider Demographics
NPI:1760646020
Name:FAWBUSH, LORI LEIGH (APN)
Entity type:Individual
Prefix:MS
First Name:LORI
Middle Name:LEIGH
Last Name:FAWBUSH
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:LEIGH
Other - Last Name:OLIVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11230 HOLLYRIDGE CV
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-9337
Mailing Address - Country:US
Mailing Address - Phone:501-834-3892
Mailing Address - Fax:
Practice Address - Street 1:11230 HOLLYRIDGE CV
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-9337
Practice Address - Country:US
Practice Address - Phone:501-834-3892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01729363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARQ02931Medicare UPIN