Provider Demographics
NPI:1376026492
Name:KOSLOV, REBECCA EDWARDS
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:EDWARDS
Last Name:KOSLOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 PINE LAWN PKWY
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-9167
Mailing Address - Country:US
Mailing Address - Phone:608-698-6171
Mailing Address - Fax:
Practice Address - Street 1:2880 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3644
Practice Address - Country:US
Practice Address - Phone:608-698-6171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8803363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1598784555OtherUWMF