Provider Demographics
NPI:1659642841
Name:DAGENHARDT, SAMANTHA GREGORY (RN, MS, MSN, PMHCNS-)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:GREGORY
Last Name:DAGENHARDT
Suffix:
Gender:F
Credentials:RN, MS, MSN, PMHCNS-
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1813
Mailing Address - Country:US
Mailing Address - Phone:262-284-8200
Mailing Address - Fax:262-284-8103
Practice Address - Street 1:121 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1813
Practice Address - Country:US
Practice Address - Phone:262-284-8157
Practice Address - Fax:262-284-8209
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4747-33363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI170792-30OtherRN
WI4747-33OtherAPNP
WI1659642841Medicaid
WI100028338Medicaid
WI100028338Medicaid
K400203513Medicare PIN