Provider Demographics
NPI:1194925479
Name:BOEHM, DAISY A (NP)
Entity type:Individual
Prefix:
First Name:DAISY
Middle Name:A
Last Name:BOEHM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3232 N BALLARD RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-8804
Mailing Address - Country:US
Mailing Address - Phone:920-749-9668
Mailing Address - Fax:920-734-5307
Practice Address - Street 1:3925 N GATEWAY DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7863
Practice Address - Country:US
Practice Address - Phone:920-749-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3137363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1194925479Medicaid
WI001345450Medicare PIN