Provider Demographics
NPI:1194272781
Name:WACHSMUTH, REBECCA LEIGH
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LEIGH
Last Name:WACHSMUTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LEIGH
Other - Last Name:MARQUARDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:114 S 20TH AVE W STE A
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55806-3526
Mailing Address - Country:US
Mailing Address - Phone:218-721-4732
Mailing Address - Fax:218-491-7185
Practice Address - Street 1:1731 W SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55806-2136
Practice Address - Country:US
Practice Address - Phone:218-721-4732
Practice Address - Fax:218-491-7185
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP4740363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health