Provider Demographics
NPI:1134752934
Name:DOUGLASS, DENISE
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 NORTHSTAR LN
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-9005
Mailing Address - Country:US
Mailing Address - Phone:715-441-2628
Mailing Address - Fax:
Practice Address - Street 1:31 NORTHSTAR LN
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-9005
Practice Address - Country:US
Practice Address - Phone:715-441-2628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty