1447365598 NPI number — REBECCA PRUELLA ANDERSON NP

Table of content: REBECCA PRUELLA ANDERSON NP (NPI 1447365598)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447365598 NPI number — REBECCA PRUELLA ANDERSON NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
REBECCA
Provider Middle Name:
PRUELLA
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:
1447365598
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N17W24100 RIVERWOOD DR STE 250
Provider Second Line Business Mailing Address:
PROHEALTH CARE MEDICAL ASSOCIATES
Provider Business Mailing Address City Name:
WAUKESHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53188-1177
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-473-5655
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
785 SUMMIT AVE STE 101
Provider Second Line Business Practice Location Address:
PROHEALTH CARE WOMEN'S CENTER
Provider Business Practice Location Address City Name:
OCONOMOWOC
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53066-3844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-569-0345
Provider Business Practice Location Address Fax Number:
262-569-0333
Provider Enumeration Date:
08/20/2006

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: 363LA2200X , with the licence number:  2574-033 , 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: 41266700 . This is a "WISCONSIN MEDICAID PROGRAM" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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