Provider Demographics
NPI:1104202506
Name:DALLENBACH, KEITH JR (RN, ACNPC-AG)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:DALLENBACH
Suffix:JR
Gender:M
Credentials:RN, ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:INFECTIOUS DISEASES
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-0746
Mailing Address - Fax:414-805-0748
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:INFECTIOUS DISEASES
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-0746
Practice Address - Fax:414-805-0748
Is Sole Proprietor?:No
Enumeration Date:2015-08-07
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI179816363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care