Provider Demographics
NPI:1225445372
Name:SNICKLES, REBECCA (FNP-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:SNICKLES
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:BOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:1644 STATE ROUTE 3
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:12913-1814
Mailing Address - Country:US
Mailing Address - Phone:518-524-0720
Mailing Address - Fax:
Practice Address - Street 1:1644 STATE ROUTE 3
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:12913-1814
Practice Address - Country:US
Practice Address - Phone:518-524-0720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY338821363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY338821OtherNURSING LICENSE