Provider Demographics
NPI:1174867188
Name:MADER, REBECCA J (RN)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:MADER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 3011
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82717
Mailing Address - Country:US
Mailing Address - Phone:307-688-5002
Mailing Address - Fax:307-688-5069
Practice Address - Street 1:501 SOUTH BURMA AVE.
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716
Practice Address - Country:US
Practice Address - Phone:307-688-5002
Practice Address - Fax:307-688-5069
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY13435163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse