Provider Demographics
NPI:1417253477
Name:WILD, REBECCA WILD (RN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:WILD
Last Name:WILD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
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Mailing Address - Street 1:3097 PRAIRIE ST SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2000
Mailing Address - Country:US
Mailing Address - Phone:616-531-9973
Mailing Address - Fax:616-531-5577
Practice Address - Street 1:2236 MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-5799
Practice Address - Country:US
Practice Address - Phone:651-659-0208
Practice Address - Fax:651-659-0161
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-08
Last Update Date:2022-08-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MNR 181142-1163W00000X
MI4704377570163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN868K1CAOtherBCBS