Provider Demographics
NPI:1447365598
Name:ANDERSON, REBECCA PRUELLA (NP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:PRUELLA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NP
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:N17W24100 RIVERWOOD DR STE 250
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1177
Mailing Address - Country:US
Mailing Address - Phone:262-473-5655
Mailing Address - Fax:
Practice Address - Street 1:785 SUMMIT AVE STE 101
Practice Address - Street 2:PROHEALTH CARE WOMEN'S CENTER
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3844
Practice Address - Country:US
Practice Address - Phone:262-569-0345
Practice Address - Fax:262-569-0333
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI2574-033363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41266700OtherWISCONSIN MEDICAID PROGRAM
WI41266700OtherWISCONSIN MEDICAID PROGRAM