Basic Information
Provider Information | |||||||||
NPI: | 1316398589 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SOTOLA | ||||||||
FirstName: | DINA | ||||||||
MiddleName: | PAULETTE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | THOMAS | ||||||||
OtherFirstName: | DINA | ||||||||
OtherMiddleName: | PAULETTE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 126 ERIN RD | ||||||||
Address2: |   | ||||||||
City: | OCONOMOWOC | ||||||||
State: | WI | ||||||||
PostalCode: | 530668802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7088465994 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2428 N GRANDVIEW BLVD STE 102 | ||||||||
Address2: |   | ||||||||
City: | WAUKESHA | ||||||||
State: | WI | ||||||||
PostalCode: | 531886906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2628755070 | ||||||||
FaxNumber: | 8663849486 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2016 | ||||||||
LastUpdateDate: | 08/12/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209.041387 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.