Provider Demographics
NPI:1194952549
Name:GLAS, LORELEI E
Entity type:Individual
Prefix:
First Name:LORELEI
Middle Name:E
Last Name:GLAS
Suffix:
Gender:F
Credentials:
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 1005
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121
Mailing Address - Country:US
Mailing Address - Phone:262-741-3200
Mailing Address - Fax:262-741-3217
Practice Address - Street 1:W4051 COUNTY RD NN
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121
Practice Address - Country:US
Practice Address - Phone:262-741-3200
Practice Address - Fax:262-741-3217
Is Sole Proprietor?:No
Enumeration Date:2009-06-12
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI303098-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse