Provider Demographics
NPI:1750474755
Name:WALLINGA, DANIELLE (PA)
Entity Type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:
Last Name:WALLINGA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25410 PARK AVE
Mailing Address - Street 2:APARTMENT E
Mailing Address - City:NIOBRARA
Mailing Address - State:NE
Mailing Address - Zip Code:68760-7044
Mailing Address - Country:US
Mailing Address - Phone:402-857-3398
Mailing Address - Fax:402-857-3315
Practice Address - Street 1:25410 PARK AVE
Practice Address - Street 2:APARTMENT E
Practice Address - City:NIOBRARA
Practice Address - State:NE
Practice Address - Zip Code:68760-7044
Practice Address - Country:US
Practice Address - Phone:402-857-3398
Practice Address - Fax:402-857-3315
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE908363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025001900Medicaid
NE9955OtherMIDLANDS CHOICE
SD5300850OtherMEDICAID
NE9210187OtherDAKOTACARE
NE30387OtherBLUE SHIELD
SD5300850Medicaid
NE10025001900Medicaid
NE9955OtherMIDLANDS CHOICE