Provider Demographics
NPI:1679767479
Name:DILLABER, JOLIE A (RN)
Entity type:Individual
Prefix:
First Name:JOLIE
Middle Name:A
Last Name:DILLABER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W399 CTY HWY L
Mailing Address - Street 2:
Mailing Address - City:EAST TROY
Mailing Address - State:WI
Mailing Address - Zip Code:53120
Mailing Address - Country:US
Mailing Address - Phone:262-490-7997
Mailing Address - Fax:
Practice Address - Street 1:104 GEORGE ST
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3504
Practice Address - Country:US
Practice Address - Phone:262-691-1299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI350-38-900Medicaid