Provider Demographics
NPI:1528131752
Name:FAFARA, LAURA LEE (ATC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LEE
Last Name:FAFARA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16223 W EASY ST
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-2586
Mailing Address - Country:US
Mailing Address - Phone:715-634-2257
Mailing Address - Fax:
Practice Address - Street 1:11134 N STATE ROAD 77
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-5325
Practice Address - Country:US
Practice Address - Phone:715-634-5505
Practice Address - Fax:715-634-5558
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI396-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer