Healthcare Provider Details

I. General information

NPI: 1568914737
Provider Name (Legal Business Name): LAUREL D REW RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2016
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W7140 GILLETTE DR
DALTON WI
53926-9361
US

IV. Provider business mailing address

1109 SILVER DR APT 6
BARABOO WI
53913-8928
US

V. Phone/Fax

Practice location:
  • Phone: 312-204-9617
  • Fax:
Mailing address:
  • Phone: 312-204-9617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number98096-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: