Healthcare Provider Details

I. General information

NPI: 1710558630
Provider Name (Legal Business Name): EMILY DODGE DNP APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMILY GERRITS

II. Dates (important events)

Enumeration Date: 07/02/2021
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 E CAPITOL DR STE 1700
APPLETON WI
54911-8735
US

IV. Provider business mailing address

2000 E MILESTONE DR
APPLETON WI
54913-6701
US

V. Phone/Fax

Practice location:
  • Phone: 920-731-8131
  • Fax: 920-832-0444
Mailing address:
  • Phone: 920-358-1729
  • Fax: 920-832-0444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number225906
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number548887
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number762335
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: