Provider Demographics
NPI:1205309226
Name:RAESE, DEREK DALE
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:DALE
Last Name:RAESE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:568 N PALM ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2845
Mailing Address - Country:US
Mailing Address - Phone:608-718-3260
Mailing Address - Fax:
Practice Address - Street 1:16320 W MARIETTA DR
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-6594
Practice Address - Country:US
Practice Address - Phone:414-640-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI321484164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse