Provider Demographics
NPI:1609845692
Name:FARGO, LISA MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:FARGO
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 1:301 JUSTIN DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOREB
Mailing Address - State:WI
Mailing Address - Zip Code:53572-3306
Mailing Address - Country:US
Mailing Address - Phone:608-437-6254
Mailing Address - Fax:
Practice Address - Street 1:334 JUSTIN DR
Practice Address - Street 2:
Practice Address - City:MOUNT HOREB
Practice Address - State:WI
Practice Address - Zip Code:53572-2199
Practice Address - Country:US
Practice Address - Phone:608-437-4220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse