Healthcare Provider Details

I. General information

NPI: 1629451786
Provider Name (Legal Business Name): VIRGINIA LANTZ L.P.N
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W1026 GREEN RD
GENOA CITY WI
53128-1448
US

IV. Provider business mailing address

PO BOX 18
GENOA CITY WI
53128-0018
US

V. Phone/Fax

Practice location:
  • Phone: 262-949-8816
  • Fax:
Mailing address:
  • Phone: 262-949-8816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number311842-031
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: