Provider Demographics
NPI:1609122043
Name:DAHL, NISSA RAE (PHARMD)
Entity Type:Individual
Prefix:MISS
First Name:NISSA
Middle Name:RAE
Last Name:DAHL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1346
Mailing Address - Country:US
Mailing Address - Phone:262-767-0697
Mailing Address - Fax:
Practice Address - Street 1:680 MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1346
Practice Address - Country:US
Practice Address - Phone:262-767-0697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-02
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16817-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist