Provider Demographics
NPI:1003538281
Name:HALE, REBECCA LYNN
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:HALE
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 1:200 ELM ST
Mailing Address - Street 2:
Mailing Address - City:ILION
Mailing Address - State:NY
Mailing Address - Zip Code:13357-2504
Mailing Address - Country:US
Mailing Address - Phone:315-360-3963
Mailing Address - Fax:
Practice Address - Street 1:271 GRANT AVE STE 100
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-1407
Practice Address - Country:US
Practice Address - Phone:315-704-1407
Practice Address - Fax:315-704-6098
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY351267363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program