=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972090207
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEAH PLAISIER MORTENSEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2018
-----------------------------------------------------
Last Update Date | 09/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3111 W RAWSON AVE
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53132-9417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-260-5544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1635 N WATER ST APT 424
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53202-3661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-731-7457
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | 81997
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------