Provider Demographics
NPI:1164476156
Name:POLFUSS, MICHELE L (NP)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:L
Last Name:POLFUSS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 2ND ST
Mailing Address - Street 2:CHW-FOX VALLEY THEDA CLARK MED CTR
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2883
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CHW-FOX VALLEY THEDA CLARK MED CTR
Practice Address - Street 2:130 SECOND STREET
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956
Practice Address - Country:US
Practice Address - Phone:920-969-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1628363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43972900Medicaid
007000261YOtherHUMANA
WI43972900Medicaid