Provider Demographics
NPI:1073532511
Name:DAGEFOERDE, NANCY GAYLE (NP, APN)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:GAYLE
Last Name:DAGEFOERDE
Suffix:
Gender:F
Credentials:NP, APN
Other - Prefix:MR
Other - First Name:NANCY
Other - Middle Name:GAYLE
Other - Last Name:HALBERSTADT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP, APN
Mailing Address - Street 1:PO BOX 6003
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61126-6003
Mailing Address - Country:US
Mailing Address - Phone:815-398-3000
Mailing Address - Fax:815-391-5096
Practice Address - Street 1:444 ROXBURY ROAD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5059
Practice Address - Country:US
Practice Address - Phone:815-398-3000
Practice Address - Fax:815-398-3041
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209002451363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK24336Medicare PIN
ILIL1959014Medicare UPIN
ILS96020Medicare UPIN