Basic Information
| Provider Information | |||||||||
| NPI: | 1629219944 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAUCK | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7096 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952670096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099567725 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6308 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626562011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2009 | ||||||||
| LastUpdateDate: | 09/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 165541 | WI | N | Nursing Service Providers | Registered Nurse | 163W00000X | RN160242 | AZ | N | Nursing Service Providers | Registered Nurse | 367500000X | CRNA0645 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.