=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083903058
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REEBA ANNIE PRINCE M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2011
-----------------------------------------------------
Last Update Date | 08/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7809 100TH ST
-----------------------------------------------------
City | PLEASANT PRAIRIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53158-2806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-345-2358
-----------------------------------------------------
Fax | 262-912-0137
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 YORK ST
-----------------------------------------------------
City | MANITOWOC
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54220-4630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-663-9008
-----------------------------------------------------
Fax | 920-684-1439
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZD0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology (Pathology) Physician
-----------------------------------------------------
License Number | 13616-320
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | 13616-320
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | 125.060254
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | ME136900
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207ND0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology Physician
-----------------------------------------------------
License Number | 13616-320
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------