Healthcare Provider Details

I. General information

NPI: 1023433554
Provider Name (Legal Business Name): LORI A HEUSER BSN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2014
Last Update Date: 03/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ABBEY SPRINGS DR
FONTANA WI
53125-1822
US

IV. Provider business mailing address

200 ABBEY SPRINGS DR
FONTANA WI
53125-1822
US

V. Phone/Fax

Practice location:
  • Phone: 224-622-5866
  • Fax:
Mailing address:
  • Phone: 224-622-5866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number199468-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: