Healthcare Provider Details

I. General information

NPI: 1174390967
Provider Name (Legal Business Name): LEONORA MITRE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 W PIONEER RD
FOND DU LAC WI
54935-6151
US

IV. Provider business mailing address

55 W PIONEER RD
FOND DU LAC WI
54935-6151
US

V. Phone/Fax

Practice location:
  • Phone: 920-921-9898
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number21526-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: