Provider Demographics
NPI:1710108584
Name:LAROSE, DEBORAH KAY (LPN)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:KAY
Last Name:LAROSE
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:P.O. BOX 890
Mailing Address - Street 2:
Mailing Address - City:NEW MUNSTER
Mailing Address - State:WI
Mailing Address - Zip Code:53152-0890
Mailing Address - Country:US
Mailing Address - Phone:262-903-9295
Mailing Address - Fax:
Practice Address - Street 1:207 HAYSTACK LANE
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-0754
Practice Address - Country:US
Practice Address - Phone:262-723-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38317100Medicaid