Provider Demographics
NPI:1275025231
Name:DIVACK, REBECCA JANE
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JANE
Last Name:DIVACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18607 KUYKENDAHL RD
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77379-3453
Mailing Address - Country:US
Mailing Address - Phone:281-370-1122
Mailing Address - Fax:281-370-1139
Practice Address - Street 1:18607 KUYKENDAHL RD
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-3453
Practice Address - Country:US
Practice Address - Phone:281-370-1122
Practice Address - Fax:281-370-1139
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1110084363LP0200X
TX826074163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics