Provider Demographics
NPI:1912237389
Name:KEITH, REBECCA (FNP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:KEITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 617
Mailing Address - Street 2:312 BUSINESS HYW 53, SUITE 7
Mailing Address - City:MINONG
Mailing Address - State:WI
Mailing Address - Zip Code:54859-0617
Mailing Address - Country:US
Mailing Address - Phone:715-466-4400
Mailing Address - Fax:715-466-4401
Practice Address - Street 1:312 BUSINESS 53 STE 7
Practice Address - Street 2:
Practice Address - City:MINONG
Practice Address - State:WI
Practice Address - Zip Code:54859-9550
Practice Address - Country:US
Practice Address - Phone:715-466-4400
Practice Address - Fax:715-466-4401
Is Sole Proprietor?:No
Enumeration Date:2010-01-07
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI130019-30163W00000X
WI3947-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse