Provider Demographics
NPI:1174985444
Name:RICKBORN, LANETTE (MD)
Entity type:Individual
Prefix:
First Name:LANETTE
Middle Name:
Last Name:RICKBORN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5703
Mailing Address - Country:US
Mailing Address - Phone:800-782-8581
Mailing Address - Fax:
Practice Address - Street 1:1447 HARPER STREET MEDICAL OFFICE BUILDING SUITE 4G
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-5703
Practice Address - Country:US
Practice Address - Phone:706-721-3042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-24
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI83316-20208800000X
NV20791208800000X
390200000X
GA101113208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program