Provider Demographics
NPI:1245801604
Name:DAVIDHIZAR, REBECCA J (AGACNP-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:DAVIDHIZAR
Suffix:
Gender:F
Credentials:AGACNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6983 HILLSDALE CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2054
Mailing Address - Country:US
Mailing Address - Phone:317-849-8350
Mailing Address - Fax:317-576-6311
Practice Address - Street 1:8402 HARCOURT RD STE 615
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2055
Practice Address - Country:US
Practice Address - Phone:317-806-6991
Practice Address - Fax:317-806-6990
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28185696A363LA2100X, 163W00000X
IN71011737A363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300056365Medicaid