Provider Demographics
NPI:1053984658
Name:DAILEY, REBECCA CAITLYN
Entity type:Individual
Prefix:MISS
First Name:REBECCA
Middle Name:CAITLYN
Last Name:DAILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5048 GINNOW RD
Mailing Address - Street 2:
Mailing Address - City:OMRO
Mailing Address - State:WI
Mailing Address - Zip Code:54963-9352
Mailing Address - Country:US
Mailing Address - Phone:920-420-8778
Mailing Address - Fax:
Practice Address - Street 1:404 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-4957
Practice Address - Country:US
Practice Address - Phone:920-420-8778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4368-403246ZA2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, Medical