Provider Demographics
NPI:1063655306
Name:HYSELL, REBECCA (LMP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:HYSELL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4639 NW LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-1767
Mailing Address - Country:US
Mailing Address - Phone:360-906-0108
Mailing Address - Fax:
Practice Address - Street 1:2004 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3327
Practice Address - Country:US
Practice Address - Phone:360-993-8868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-16
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00013337174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist