Provider Demographics
NPI:1265894539
Name:POTRATZ, LAURIE BETH
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:BETH
Last Name:POTRATZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:BETH
Other - Last Name:SIMONDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1120 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:UNION GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53182-1328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1120 MAIN ST
Practice Address - Street 2:
Practice Address - City:UNION GROVE
Practice Address - State:WI
Practice Address - Zip Code:53182-1328
Practice Address - Country:US
Practice Address - Phone:262-548-6903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-24
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI68177207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine