Provider Demographics
NPI:1669515276
Name:WHITE, REBECCA JANE (RD CDE)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:JANE
Last Name:WHITE
Suffix:
Gender:F
Credentials:RD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4831 FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:PLOVER
Mailing Address - State:WI
Mailing Address - Zip Code:54467-4207
Mailing Address - Country:US
Mailing Address - Phone:715-422-9287
Mailing Address - Fax:715-422-9353
Practice Address - Street 1:1041 HILL STREET
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54495
Practice Address - Country:US
Practice Address - Phone:715-421-7566
Practice Address - Fax:715-422-9353
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI719126133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP60885Medicare UPIN