Provider Demographics
NPI:1295971422
Name:PROSEN, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:PROSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15560 76TH CT NE
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55330-3005
Mailing Address - Country:US
Mailing Address - Phone:773-306-6840
Mailing Address - Fax:
Practice Address - Street 1:9325 UPLAND LN N STE 360
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4463
Practice Address - Country:US
Practice Address - Phone:612-322-6905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-17
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5873363LN0005X
MN9971363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care