=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811409378
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA LYNN BURGESS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2017
-----------------------------------------------------
Last Update Date | 10/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 840 STATE ROAD 136
-----------------------------------------------------
City | BARABOO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53913-9233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-477-9858
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 417 HITCHCOCK ST
-----------------------------------------------------
City | BARABOO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53913-2876
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------