1427689074 NPI number — TAYLOR RAE ROTHERHAM-DECREMER NP

Table of content: TAYLOR RAE ROTHERHAM-DECREMER NP (NPI 1427689074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427689074 NPI number — TAYLOR RAE ROTHERHAM-DECREMER NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROTHERHAM-DECREMER
Provider First Name:
TAYLOR
Provider Middle Name:
RAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427689074
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 22487
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54305-2487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-445-7210
Provider Business Mailing Address Fax Number:
920-445-7289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1920 LIBAL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54301-2471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-436-8691
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/03/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  9464-33 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: F07191161 . This is a "AMERICAN ACADEMY OF NURSE PRACTITIONERS" identifier . This identifiers is of the category "OTHER".