Healthcare Provider Details

I. General information

NPI: 1568798700
Provider Name (Legal Business Name): REBECCA L. WERTISH CERTIFIED FAMILY NUR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2009
Last Update Date: 02/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CENTRACARE CIRCLE, #2300 CENTRACARE CLINIC WOMEN'S & CHILDRENS/OB0GYN
ST CLOUD MN
56303-5000
US

IV. Provider business mailing address

1900 CENTRACARE CIRCLE, #2300 CENTRACARE CLINIC WOMEN'S & CHILDRENS/OB0GYN
ST CLOUD MN
56303-5000
US

V. Phone/Fax

Practice location:
  • Phone: 320-654-3630
  • Fax:
Mailing address:
  • Phone: 320-654-3630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR-137104-2
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: