Provider Demographics
NPI:1386936201
Name:VANDEBERG, DANIELLE M (PA)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:M
Last Name:VANDEBERG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:M
Other - Last Name:GILLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:414-525-2400
Mailing Address - Fax:
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:414-525-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10958363A00000X
MN014695363A00000X
MN1570363A00000X
390200000X
WI3298363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNPO1053637OtherMEDICARE RAILROAD
WI100038810Medicaid