Provider Demographics
NPI:1508400698
Name:HER, MAIKHOU LOR (RN)
Entity Type:Individual
Prefix:
First Name:MAIKHOU
Middle Name:LOR
Last Name:HER
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 1:2754 BURRITT RD
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-3383
Mailing Address - Country:US
Mailing Address - Phone:608-556-6681
Mailing Address - Fax:
Practice Address - Street 1:214 S FORREST ST STE L1
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-1713
Practice Address - Country:US
Practice Address - Phone:608-889-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
WI251098-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator