Provider Demographics
NPI:1912243924
Name:TABATABAEI DAKHILI, KATAYONSADAT (APNP)
Entity Type:Individual
Prefix:
First Name:KATAYONSADAT
Middle Name:
Last Name:TABATABAEI DAKHILI
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 W BRUCE ST
Mailing Address - Street 2:#200
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-1667
Mailing Address - Country:US
Mailing Address - Phone:414-384-1400
Mailing Address - Fax:
Practice Address - Street 1:130 W BRUCE ST
Practice Address - Street 2:#200
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-1667
Practice Address - Country:US
Practice Address - Phone:414-384-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5171363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100027445Medicaid