Provider Demographics
NPI:1811492929
Name:DANIELS, KATIE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:DANIELS
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 1:8405 COUNTY ROAD CC
Mailing Address - Street 2:
Mailing Address - City:OCONTO FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54154-9506
Mailing Address - Country:US
Mailing Address - Phone:920-373-4657
Mailing Address - Fax:
Practice Address - Street 1:530 SMITH AVE
Practice Address - Street 2:
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153-1010
Practice Address - Country:US
Practice Address - Phone:920-834-7600
Practice Address - Fax:920-834-7601
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8316363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100078233Medicaid