Provider Demographics
NPI:1033196530
Name:DELISA, REBECCA ANN (NP)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:ANN
Last Name:DELISA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:354 BIRNIE AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1109
Mailing Address - Country:US
Mailing Address - Phone:413-733-3470
Mailing Address - Fax:413-732-4216
Practice Address - Street 1:354 BIRNIE AVE STE 202
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1109
Practice Address - Country:US
Practice Address - Phone:413-733-3470
Practice Address - Fax:413-732-4216
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA206128363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0376060Medicaid
500029005Medicare PIN
P41320Medicare UPIN
MA0376060Medicaid