Basic Information
| Provider Information | |||||||||
| NPI: | 1801235858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOERICKE | ||||||||
| FirstName: | LORA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | APNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LANGE | ||||||||
| OtherFirstName: | LORA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 888 THACKERAY TRL 103 | ||||||||
| Address2: | |||||||||
| City: | OCONOMOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530664342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623543744 | ||||||||
| FaxNumber: | 2623543748 | ||||||||
| Practice Location | |||||||||
| Address1: | 1145 W MAIN AVE | ||||||||
| Address2: | STE. 205 | ||||||||
| City: | DE PERE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541151698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203366455 | ||||||||
| FaxNumber: | 9203366646 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2013 | ||||||||
| LastUpdateDate: | 12/16/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 5317 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.