Provider Demographics
NPI:1649447764
Name:LOFTUS, SHARON (MT)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:LOFTUS
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N63W23524 SILVER SPRING DR # 4
Mailing Address - Street 2:
Mailing Address - City:SUSSEX
Mailing Address - State:WI
Mailing Address - Zip Code:53089-3833
Mailing Address - Country:US
Mailing Address - Phone:262-246-8410
Mailing Address - Fax:262-246-8894
Practice Address - Street 1:N63W23524 SILVER SPRING DR # 4
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089-3833
Practice Address - Country:US
Practice Address - Phone:262-246-8410
Practice Address - Fax:262-246-8894
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1003046174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1003046OtherSTATE LICENSE
WI27929900OtherNATIONAL CERTIFICATION BOARD #