Provider Demographics
NPI:1477594315
Name:AL-DHARI, LAWANA GBRYANT (RN)
Entity Type:Individual
Prefix:
First Name:LAWANA
Middle Name:GBRYANT
Last Name:AL-DHARI
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14113
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-0113
Mailing Address - Country:US
Mailing Address - Phone:414-630-0503
Mailing Address - Fax:
Practice Address - Street 1:2151 S MOUND ST
Practice Address - Street 2:
Practice Address - City:BAYVIEW
Practice Address - State:WI
Practice Address - Zip Code:53207-1331
Practice Address - Country:US
Practice Address - Phone:414-630-0503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI77548-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39805000Medicaid