Provider Demographics
NPI:1174034102
Name:ANDERSON, REBECCA (NURSE)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8109 INTERSTATE 30
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72209-4840
Mailing Address - Country:US
Mailing Address - Phone:501-562-5400
Mailing Address - Fax:
Practice Address - Street 1:8109 INTERSTATE 30
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-4840
Practice Address - Country:US
Practice Address - Phone:501-562-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR095143164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
163W00000XOtherNURSE