Basic Information
| Provider Information | |||||||||
| NPI: | 1659642841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAGENHARDT | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | GREGORY | ||||||||
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| Credential: | RN, MS, MSN, PMHCNS- | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PORT WASHINGTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530741813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622848200 | ||||||||
| FaxNumber: | 2622848103 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PORT WASHINGTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530741813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622848157 | ||||||||
| FaxNumber: | 2622848209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2012 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4747-33 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0808X | 4747-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 170792-30 | 01 | WI | RN | OTHER | 4747-33 | 01 | WI | APNP | OTHER | MG2558685 | 01 | DEA | OTHER | 1659642841 | 05 | WI | MEDICAID | 100028338 | 05 | WI | MEDICAID |