Provider Demographics
NPI:1912257700
Name:BORGH, DAYNE RAE
Entity Type:Individual
Prefix:
First Name:DAYNE
Middle Name:RAE
Last Name:BORGH
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 1:935 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-0198
Mailing Address - Country:US
Mailing Address - Phone:262-646-3361
Mailing Address - Fax:
Practice Address - Street 1:935 MAIN STREET
Practice Address - Street 2:
Practice Address - City:DELAFIELD
Practice Address - State:WI
Practice Address - Zip Code:53018-0198
Practice Address - Country:US
Practice Address - Phone:262-646-3361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0940374T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374T00000XNursing Service Related ProvidersReligious Nonmedical Nursing Personnel
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI00390Medicare PIN