MEDICARE: DARCIE RODEBACK RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	265100-30	WI
2	163WP0200X	Pediatric Registered Nurse	265100-30	WI

General Provider Information

NPI Number	:	1962180786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARCIE RODEBACK RN

Provider Business Mailing Address
First Line	:	1210 RIDGE RD
Second Line	:
City	:	CUSTER
State	:	WI
Zip	:	54423-9430
Country	:	US
Telephone Number	:	715-240-0294
Fax Number	:

Provider Business Practice Location Address
First Line	:	1210 RIDGE RD
Second Line	:
City	:	CUSTER
State	:	WI
Zip	:	54423-9430
Country	:	US
Telephone Number	:	715-240-0294
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2023
Last Update Date	:	07/11/2023

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Directions to “ DARCIE RODEBACK RN” Practice Location

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