Provider Demographics
NPI:1396368890
Name:PATTERSON, LARA MICHELLE (LAC)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:MICHELLE
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 PLEASANT LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53405-4839
Mailing Address - Country:US
Mailing Address - Phone:608-358-2830
Mailing Address - Fax:
Practice Address - Street 1:4010 PLEASANT LN
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53405-4839
Practice Address - Country:US
Practice Address - Phone:608-358-2830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI997-55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI997-55OtherDEPT OF SAFETY AND PROFESSIONAL SERVICES