Provider Demographics
NPI:1669669768
Name:KLUSSENDORF, REBEKAH K (NP)
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:K
Last Name:KLUSSENDORF
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9875 S FRANKLIN DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-8895
Mailing Address - Country:US
Mailing Address - Phone:414-858-2206
Mailing Address - Fax:414-858-2236
Practice Address - Street 1:2900 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4330
Practice Address - Country:US
Practice Address - Phone:414-385-8723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3223-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner