Provider Demographics
NPI:1265568968
Name:GOUTHRO, LISA (RN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GOUTHRO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3981 S VICTORIA CT
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-9002
Mailing Address - Country:US
Mailing Address - Phone:262-797-8358
Mailing Address - Fax:
Practice Address - Street 1:3981 S VICTORIA CT
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-9002
Practice Address - Country:US
Practice Address - Phone:262-797-8358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0128903-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38236100Medicaid