Provider Demographics
NPI:1104548536
Name:OWENS, LARESA ALEXIS SHANAE (CNA, CBRF)
Entity type:Individual
Prefix:
First Name:LARESA
Middle Name:ALEXIS SHANAE
Last Name:OWENS
Suffix:
Gender:F
Credentials:CNA, CBRF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6629 W CHARLES CT
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-9268
Mailing Address - Country:US
Mailing Address - Phone:414-737-1042
Mailing Address - Fax:
Practice Address - Street 1:3422 N 2ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-1557
Practice Address - Country:US
Practice Address - Phone:414-737-1042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI00197312374U00000X
WIWI031910101915376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No374U00000XNursing Service Related ProvidersHome Health Aide