Provider Demographics
NPI:1346989225
Name:MILLARD, REBECCA LYN (RN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYN
Last Name:MILLARD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1496 W HOOSIER BLVD
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-3727
Mailing Address - Country:US
Mailing Address - Phone:765-472-5043
Mailing Address - Fax:
Practice Address - Street 1:1496 W HOOSIER BLVD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-3727
Practice Address - Country:US
Practice Address - Phone:765-472-5043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28168564C163W00000X
IN28168564A163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163W00000XNursing Service ProvidersRegistered Nurse