Basic Information
| Provider Information | |||||||||
| NPI: | 1235782772 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLEGA | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 W MOHAWK DR | ||||||||
| Address2: | |||||||||
| City: | TOMAHAWK | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544872274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154537700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 401 W MOHAWK DR | ||||||||
| Address2: | |||||||||
| City: | TOMAHAWK | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544872274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154537700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2019 | ||||||||
| LastUpdateDate: | 11/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 9578-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163WC0200X | 171656 | WI | N | Nursing Service Providers | Registered Nurse | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | F07191563 | 01 | WI | AANP | OTHER |