Provider Demographics
NPI:1144620501
Name:SUMMERS, REBECCA FULLER
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:FULLER
Last Name:SUMMERS
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 1:260 NEWPORT CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7522
Mailing Address - Country:US
Mailing Address - Phone:949-422-2553
Mailing Address - Fax:
Practice Address - Street 1:260 NEWPORT CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7522
Practice Address - Country:US
Practice Address - Phone:949-422-2553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1992022917390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program