Provider Demographics
NPI:1760752752
Name:PRUSKY, LAUREN E (IDMT)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:E
Last Name:PRUSKY
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-7378
Mailing Address - Country:US
Mailing Address - Phone:920-252-2586
Mailing Address - Fax:
Practice Address - Street 1:80 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-7378
Practice Address - Country:US
Practice Address - Phone:920-252-2586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians