Provider Demographics
NPI:1548533623
Name:BECKER, DEBRA JO (CERTIFIED NURSING AS)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:JO
Last Name:BECKER
Suffix:
Gender:F
Credentials:CERTIFIED NURSING AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074
Mailing Address - Country:US
Mailing Address - Phone:262-284-8200
Mailing Address - Fax:262-284-8103
Practice Address - Street 1:121 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074
Practice Address - Country:US
Practice Address - Phone:262-284-8200
Practice Address - Fax:262-284-8103
Is Sole Proprietor?:No
Enumeration Date:2012-02-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WINA269217374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43111400Medicaid