Healthcare Provider Details

I. General information

NPI: 1609120161
Provider Name (Legal Business Name): REBECCA LYNN SHIELDS A.P.R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2012
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S 9TH ST
WATERTOWN WI
53094-6604
US

IV. Provider business mailing address

817 CHADWICK DR
WATERTOWN WI
53094-5923
US

V. Phone/Fax

Practice location:
  • Phone: 262-719-8974
  • Fax:
Mailing address:
  • Phone: 262-719-8974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number166428-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License Number166428-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: