Provider Demographics
NPI:1457697468
Name:KERKENBUSH, REBECCA LEE (RD CD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LEE
Last Name:KERKENBUSH
Suffix:
Gender:F
Credentials:RD CD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LEE
Other - Last Name:SCHICKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD CD
Mailing Address - Street 1:125 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3303
Mailing Address - Country:US
Mailing Address - Phone:920-262-4633
Mailing Address - Fax:
Practice Address - Street 1:125 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3303
Practice Address - Country:US
Practice Address - Phone:920-262-4633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1791-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000071750Medicare PIN