Provider Demographics
NPI:1255721130
Name:BOLAND, REBECCA (BSN RN)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BOLAND
Suffix:
Gender:F
Credentials:BSN RN
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:KINTOPF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, LPN, CNA
Mailing Address - Street 1:2065 MUIRFIELD WAY
Mailing Address - Street 2:
Mailing Address - City:NEW FRANKEN
Mailing Address - State:WI
Mailing Address - Zip Code:54229-9787
Mailing Address - Country:US
Mailing Address - Phone:920-606-4843
Mailing Address - Fax:
Practice Address - Street 1:2065 MUIRFIELD WAY
Practice Address - Street 2:
Practice Address - City:NEW FRANKEN
Practice Address - State:WI
Practice Address - Zip Code:54229-9787
Practice Address - Country:US
Practice Address - Phone:920-606-4843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI195714163W00000X, 163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WE0003XNursing Service ProvidersRegistered NurseEmergency