Provider Demographics
NPI:1851600092
Name:REZAC, JEROME TODD (LPN)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:TODD
Last Name:REZAC
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 E MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-2919
Mailing Address - Country:US
Mailing Address - Phone:507-373-4300
Mailing Address - Fax:507-373-4304
Practice Address - Street 1:216 E MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-2919
Practice Address - Country:US
Practice Address - Phone:507-373-4300
Practice Address - Fax:507-373-4304
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL 65492-2164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse