Provider Demographics
NPI:1457034282
Name:VAN DE WAL, RACHEL (RN, CLC)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:VAN DE WAL
Suffix:
Gender:F
Credentials:RN, CLC
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:28 LOWER BOWER RD
Mailing Address - Street 2:
Mailing Address - City:SAND LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12153-1912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28 LOWER BOWER RD
Practice Address - Street 2:
Practice Address - City:SAND LAKE
Practice Address - State:NY
Practice Address - Zip Code:12153-1912
Practice Address - Country:US
Practice Address - Phone:518-441-3624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID58110163W00000X
IL42490623163W00000X
CA95165777163W00000X
MTRN-129681163W00000X
CT150100163W00000X
KS14-143922-051163W00000X
MDT20230512163W00000X
MI4704341601163W00000X
WARN60838614163W00000X
NY688558163WL0100X
NH079341-21163W00000X
DEL1-0071640163W00000X
IN2824419OA163W00000X
GARN276845163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse