Provider Demographics
NPI:1548579139
Name:MEDIATE, LAURIE ANN (LPN)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:ANN
Last Name:MEDIATE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 N CHURCH ST
Mailing Address - Street 2:APT. 102
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-1185
Mailing Address - Country:US
Mailing Address - Phone:262-215-6947
Mailing Address - Fax:
Practice Address - Street 1:1019 N CHURCH ST
Practice Address - Street 2:APT. 102
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-1185
Practice Address - Country:US
Practice Address - Phone:262-215-6947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI312419-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse