Provider Demographics
NPI:1194995415
Name:DEFERE, NADEEN RAE (MS)
Entity type:Individual
Prefix:
First Name:NADEEN
Middle Name:RAE
Last Name:DEFERE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MRS
Other - First Name:NADEEN
Other - Middle Name:RAE
Other - Last Name:DEFERE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:140 CORPORATE DR
Mailing Address - Street 2:STE 1
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-1281
Mailing Address - Country:US
Mailing Address - Phone:920-887-2822
Mailing Address - Fax:
Practice Address - Street 1:140 CORPORATE DR
Practice Address - Street 2:STE 1
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-1281
Practice Address - Country:US
Practice Address - Phone:920-887-2822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-03
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI263-156237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41133300Medicaid