Provider Demographics
NPI:1043351778
Name:DITZENBERGER, GEORGIA R (NNP-BC, PHD)
Entity Type:Individual
Prefix:MS
First Name:GEORGIA
Middle Name:R
Last Name:DITZENBERGER
Suffix:
Gender:F
Credentials:NNP-BC, PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:608-829-5485
Mailing Address - Fax:
Practice Address - Street 1:202 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1507
Practice Address - Country:US
Practice Address - Phone:608-417-6236
Practice Address - Fax:608-417-6377
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR093006205N9 NNP-PP363LN0000X
WI3563-033363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal