Provider Demographics
NPI:1043249220
Name:REISNER, LORNA RAE (NP)
Entity type:Individual
Prefix:
First Name:LORNA
Middle Name:RAE
Last Name:REISNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:OVERGAARD
Mailing Address - State:AZ
Mailing Address - Zip Code:85933-0099
Mailing Address - Country:US
Mailing Address - Phone:928-535-6667
Mailing Address - Fax:928-535-5561
Practice Address - Street 1:218 W WHITE MOUNTAIN BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-7013
Practice Address - Country:US
Practice Address - Phone:928-367-9995
Practice Address - Fax:928-367-9988
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN039092163W00000X
AZAP0182363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
8HF049Medicare ID - Type UnspecifiedTRAILBLAZER - MEDICARE
Q64566Medicare UPIN