Healthcare Provider Details

I. General information

NPI: 1174985444
Provider Name (Legal Business Name): LANETTE RICKBORN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1447 HARPER STREET MEDICAL OFFICE BUILDING SUITE 4G
AUGUSTA GA
30912-5703
US

IV. Provider business mailing address

1000 N OAK AVE
MARSHFIELD WI
54449-5703
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-3042
  • Fax:
Mailing address:
  • Phone: 800-782-8581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number83316-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number20791
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number101113
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: