Provider Demographics
NPI:1700164472
Name:SWOBODA, THERESA POELL (RN)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:POELL
Last Name:SWOBODA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:THERESA
Other - Middle Name:MARIE
Other - Last Name:POELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3300 N 60TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-3402
Mailing Address - Country:US
Mailing Address - Phone:402-554-0520
Mailing Address - Fax:402-551-8797
Practice Address - Street 1:11111 M ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-2378
Practice Address - Country:US
Practice Address - Phone:402-504-4099
Practice Address - Fax:502-504-3929
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE42423163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE092619Medicaid