Provider Demographics
NPI:1033221106
Name:ROBERTSON, REBECCA HOLLY T (FNP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:HOLLY T
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:T
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:122 AIRWAYS PL
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5872
Mailing Address - Country:US
Mailing Address - Phone:662-349-9990
Mailing Address - Fax:662-349-2620
Practice Address - Street 1:122 AIRWAYS PL
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5872
Practice Address - Country:US
Practice Address - Phone:662-349-9990
Practice Address - Fax:662-349-2620
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR851350363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120194Medicaid
MSP96376Medicare UPIN