Provider Demographics
NPI:1992167415
Name:THEISEN, LORI JEAN (IBCLC, RN)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:JEAN
Last Name:THEISEN
Suffix:
Gender:F
Credentials:IBCLC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3268 HILLCREST RD
Mailing Address - Street 2:APARTMENT 5
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-3939
Mailing Address - Country:US
Mailing Address - Phone:563-213-3731
Mailing Address - Fax:
Practice Address - Street 1:3268 HILLCREST RD
Practice Address - Street 2:APARTMENT 5
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-3939
Practice Address - Country:US
Practice Address - Phone:563-213-3731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA142177163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant