Provider Demographics
NPI:1467919464
Name:ROETHLISBERGER, LAUREN M
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:M
Last Name:ROETHLISBERGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 APRIL LN
Mailing Address - Street 2:
Mailing Address - City:ASHWAUBENON
Mailing Address - State:WI
Mailing Address - Zip Code:54304-4103
Mailing Address - Country:US
Mailing Address - Phone:920-321-8789
Mailing Address - Fax:
Practice Address - Street 1:1115 APRIL LN
Practice Address - Street 2:
Practice Address - City:ASHWAUBENON
Practice Address - State:WI
Practice Address - Zip Code:54304-4103
Practice Address - Country:US
Practice Address - Phone:920-321-8789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer