=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194272781
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA LEIGH WACHSMUTH CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2016
-----------------------------------------------------
Last Update Date | 10/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24 N 21ST AVE W
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55806-2017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-813-0212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1015 BROADWAY ST
-----------------------------------------------------
City | SUPERIOR
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54880-1856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-813-0212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | CNP4740
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------