Healthcare Provider Details

I. General information

NPI: 1679767479
Provider Name (Legal Business Name): JOLIE A DILLABER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 GEORGE ST
PEWAUKEE WI
53072-3504
US

IV. Provider business mailing address

W399 CTY HWY L
EAST TROY WI
53120
US

V. Phone/Fax

Practice location:
  • Phone: 262-691-1299
  • Fax:
Mailing address:
  • Phone: 262-490-7997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: