Healthcare Provider Details

I. General information

NPI: 1225514656
Provider Name (Legal Business Name): LORI KOMISAR RN-BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9252 N GREEN BAY RD
BROWN DEER WI
53209-1104
US

IV. Provider business mailing address

9252 N GREEN BAY RD
MILWAUKEE WI
53209-1104
US

V. Phone/Fax

Practice location:
  • Phone: 414-527-5261
  • Fax:
Mailing address:
  • Phone: 414-527-5261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number85501-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: