Provider Demographics
NPI:1255324919
Name:EWALD, REBECCA E (MSN, CPNP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:E
Last Name:EWALD
Suffix:
Gender:F
Credentials:MSN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 RADIO HILL RD
Mailing Address - Street 2:SUITE 1 MEDICAL ARTS BUILDING
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-4224
Mailing Address - Country:US
Mailing Address - Phone:276-783-8183
Mailing Address - Fax:276-782-9267
Practice Address - Street 1:590 RADIO HILL RD
Practice Address - Street 2:SUITE 1 MEDICAL ARTS BUILDING
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-4224
Practice Address - Country:US
Practice Address - Phone:276-783-8183
Practice Address - Fax:276-782-9267
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0017137762363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0017137762OtherVIRGINIA LIS.