Basic Information
| Provider Information | |||||||||
| NPI: | 1235485731 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BIRD | ||||||||
| FirstName: | LORA | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | ANP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 GAGE BLVD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993529532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423627 | ||||||||
| FaxNumber: | 5096272983 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 GOETHALS DRIVE | ||||||||
| Address2: | SUITE F | ||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423272 | ||||||||
| FaxNumber: | 5099423273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2012 | ||||||||
| LastUpdateDate: | 04/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 18180 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | AP60519194 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 96187 | 01 | CT | RN LICENSE | OTHER | 1235485731 | 05 | WA | MEDICAID | 18180 | 01 | TN | TN BOARD OF NURSING | OTHER |