Basic Information
Provider Information | |||||||||
NPI: | 1700164472 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SWOBODA | ||||||||
FirstName: | THERESA | ||||||||
MiddleName: | POELL | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | POELL | ||||||||
OtherFirstName: | THERESA | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3300 N 60TH ST | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681043402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4025540520 | ||||||||
FaxNumber: | 4025518797 | ||||||||
Practice Location | |||||||||
Address1: | 11111 M ST | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681372378 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4025044099 | ||||||||
FaxNumber: | 5025043929 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/29/2011 | ||||||||
LastUpdateDate: | 05/09/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 42423 | NE | Y |   | Nursing Service Providers | Registered Nurse |   |
ID Information
ID | Type | State | Issuer | Description | 092619 | 05 | NE |   | MEDICAID |