Provider Demographics
NPI:1043671415
Name:ALLEYNE HOLTZCLAW, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:ALLEYNE HOLTZCLAW
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 1:40 SPRING ST
Mailing Address - Street 2:WATERTOWN
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-3474
Mailing Address - Country:US
Mailing Address - Phone:617-923-6334
Mailing Address - Fax:
Practice Address - Street 1:40 SPRING ST
Practice Address - Street 2:WATERTOWN
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-3474
Practice Address - Country:US
Practice Address - Phone:617-923-6334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA141869363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner