Healthcare Provider Details

I. General information

NPI: 1235043266
Provider Name (Legal Business Name): ELIZABETH REBOLLAR BSN,RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11112 308TH AVE
WILMOT WI
53192-7700
US

IV. Provider business mailing address

11112 308TH AVE
WILMOT WI
53192-7700
US

V. Phone/Fax

Practice location:
  • Phone: 262-862-2351
  • Fax: 262-862-6929
Mailing address:
  • Phone: 262-862-2351
  • Fax: 262-862-6929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number218938
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: