Provider Demographics
NPI:1164759379
Name:KIRK-EWING, REBECCA S (RN CDE)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:S
Last Name:KIRK-EWING
Suffix:
Gender:F
Credentials:RN CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 137
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:ID
Mailing Address - Zip Code:83522-0137
Mailing Address - Country:US
Mailing Address - Phone:208-952-3251
Mailing Address - Fax:208-962-2323
Practice Address - Street 1:701 LEWISTON ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:ID
Practice Address - Zip Code:83522-9750
Practice Address - Country:US
Practice Address - Phone:208-962-3251
Practice Address - Fax:208-962-2323
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2031-0119163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator