Provider Demographics
NPI:1003286881
Name:MARTIN, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:MARTIN
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:PO BOX 423
Mailing Address - Street 2:14 MAIDEN LANE
Mailing Address - City:PENN YAN
Mailing Address - State:NY
Mailing Address - Zip Code:14527-0423
Mailing Address - Country:US
Mailing Address - Phone:315-531-9102
Mailing Address - Fax:315-531-9103
Practice Address - Street 1:112 KIMBALL AVE
Practice Address - Street 2:
Practice Address - City:PENN YAN
Practice Address - State:NY
Practice Address - Zip Code:14527-1816
Practice Address - Country:US
Practice Address - Phone:315-531-9102
Practice Address - Fax:315-531-9103
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340055363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily