Healthcare Provider Details

I. General information

NPI: 1780211672
Provider Name (Legal Business Name): LORNA E LASTOVICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8915 W CONNELL AVE
MILWAUKEE WI
53226-3067
US

IV. Provider business mailing address

8915 W CONNELL AVE
MILWAUKEE WI
53226-3067
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number81780-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: