Provider Demographics
NPI:1417123092
Name:DEMENTIA CONSULTATIONS LLC
Entity Type:Organization
Organization Name:DEMENTIA CONSULTATIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER, SOLE PROPRIETER
Authorized Official - Prefix:MS
Authorized Official - First Name:PHILOMENA
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:RN GNP-BC
Authorized Official - Phone:608-647-6538
Mailing Address - Street 1:265 NORTH PARK STREET
Mailing Address - Street 2:
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-2208
Mailing Address - Country:US
Mailing Address - Phone:608-647-6538
Mailing Address - Fax:
Practice Address - Street 1:265 NORTH PARK STREET
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581-2208
Practice Address - Country:US
Practice Address - Phone:608-647-6538
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI964-033363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43849300Medicaid
1629079348OtherNPI TYPE 1
WI43849300Medicaid