Healthcare Provider Details

I. General information

NPI: 1104845387
Provider Name (Legal Business Name): LYNN D. REZACHEK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 SIEGLER ST
GREEN BAY WI
54303-2635
US

IV. Provider business mailing address

630 N 7TH ST
MANITOWOC WI
54220-3917
US

V. Phone/Fax

Practice location:
  • Phone: 920-497-3126
  • Fax:
Mailing address:
  • Phone: 920-684-4989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number82150-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: