Healthcare Provider Details

I. General information

NPI: 1972090207
Provider Name (Legal Business Name): LEAH PLAISIER MORTENSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 W RAWSON AVE
FRANKLIN WI
53132-9417
US

IV. Provider business mailing address

1635 N WATER ST APT 424
MILWAUKEE WI
53202-3661
US

V. Phone/Fax

Practice location:
  • Phone: 414-260-5544
  • Fax:
Mailing address:
  • Phone: 414-731-7457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number81997
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: