Healthcare Provider Details

I. General information

NPI: 1063330447
Provider Name (Legal Business Name): REBECCA EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3803 SPRING ST
MOUNT PLEASANT WI
53405-1660
US

IV. Provider business mailing address

110 WELLINGTON DR
UNION GROVE WI
53182-1804
US

V. Phone/Fax

Practice location:
  • Phone: 262-687-4011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9038-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: