Provider Demographics
NPI:1265309348
Name:REBECCA LEIGH WACHSMUTH
Entity type:Organization
Organization Name:REBECCA LEIGH WACHSMUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:WACHSMUTH
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:715-813-0212
Mailing Address - Street 1:1015 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-1856
Mailing Address - Country:US
Mailing Address - Phone:715-813-0212
Mailing Address - Fax:
Practice Address - Street 1:24 N 21ST AVE W
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55806-2017
Practice Address - Country:US
Practice Address - Phone:715-813-0212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-22
Last Update Date:2025-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty