Provider Demographics
NPI:1083137624
Name:CASTLEBERRY, REBECCA A (APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:CASTLEBERRY
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ANN
Other - Last Name:PHARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, FNP-C
Mailing Address - Street 1:108 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-6268
Mailing Address - Country:US
Mailing Address - Phone:337-540-3810
Mailing Address - Fax:
Practice Address - Street 1:2640 COUNTRY CLUB RD STE 400
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-6079
Practice Address - Country:US
Practice Address - Phone:337-426-0919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAPI34446363LF0000X
LAAP09430363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2468286Medicaid