Healthcare Provider Details

I. General information

NPI: 1811800626
Provider Name (Legal Business Name): REBECCA POULOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19121 HOBSON ST
WHITEHALL WI
54773-8652
US

IV. Provider business mailing address

19121 HOBSON ST
WHITEHALL WI
54773-8652
US

V. Phone/Fax

Practice location:
  • Phone: 715-538-4364
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number113283-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: