Healthcare Provider Details

I. General information

NPI: 1710422514
Provider Name (Legal Business Name): RAEANN MEVISSEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2017
Last Update Date: 01/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1394B 220TH AVE
NEW RICHMOND WI
54017-6112
US

IV. Provider business mailing address

1394B 220TH AVE
NEW RICHMOND WI
54017-6112
US

V. Phone/Fax

Practice location:
  • Phone: 715-781-3305
  • Fax:
Mailing address:
  • Phone: 715-781-3305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number203706-8
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number174347
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: