Provider Demographics
NPI:1114982030
Name:FANT, REBECCA (FNP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:FANT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5219 CITY BANK PKWY
Mailing Address - Street 2:SUITE 35
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-3544
Mailing Address - Country:US
Mailing Address - Phone:806-761-0707
Mailing Address - Fax:806-761-0708
Practice Address - Street 1:6002 SLIDE RD # D24
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79414-4310
Practice Address - Country:US
Practice Address - Phone:806-761-0450
Practice Address - Fax:806-796-7259
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX617399163W00000X
TXAP110620363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145684002Medicaid
TX145684002Medicaid
P31068Medicare UPIN