Healthcare Provider Details

I. General information

NPI: 1659642841
Provider Name (Legal Business Name): SAMANTHA GREGORY DAGENHARDT RN, MS, MSN, PMHCNS-
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2012
Last Update Date: 03/07/2023
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 W MAIN ST
PORT WASHINGTON WI
53074-1813
US

IV. Provider business mailing address

121 W MAIN ST
PORT WASHINGTON WI
53074-1813
US

V. Phone/Fax

Practice location:
  • Phone: 262-284-8157
  • Fax: 262-284-8209
Mailing address:
  • Phone: 262-284-8200
  • Fax: 262-284-8103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4747-33
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4747-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: