Provider Demographics
NPI:1336356336
Name:MANION, LORELLE MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:LORELLE
Middle Name:MICHELLE
Last Name:MANION
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5005
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53187-5005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1305 N BARKER RD STE 1
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-5216
Practice Address - Country:US
Practice Address - Phone:262-784-3200
Practice Address - Fax:262-784-8198
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35609208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32207500Medicaid
WI35609OtherWISCONSIN STATE LICENSE
WI68802Medicare ID - Type Unspecified
WI35609OtherWISCONSIN STATE LICENSE