Provider Demographics
NPI:1467514190
Name:VANG, LYSSA KHAM (MS, OTR)
Entity Type:Individual
Prefix:MRS
First Name:LYSSA
Middle Name:KHAM
Last Name:VANG
Suffix:
Gender:F
Credentials:MS, OTR
Other - Prefix:MRS
Other - First Name:KHAM
Other - Middle Name:KEO
Other - Last Name:XIONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, OTR
Mailing Address - Street 1:2806 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53219-3301
Mailing Address - Country:US
Mailing Address - Phone:414-329-8462
Mailing Address - Fax:
Practice Address - Street 1:2895 S MOORLAND RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-3743
Practice Address - Country:US
Practice Address - Phone:262-782-0961
Practice Address - Fax:262-782-9013
Is Sole Proprietor?:No
Enumeration Date:2006-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4120-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist