Provider Demographics
NPI:1356300362
Name:WALL, REBECCA (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 LEWIS HARGETT CIR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3590
Mailing Address - Country:US
Mailing Address - Phone:859-268-1030
Mailing Address - Fax:859-269-4120
Practice Address - Street 1:425 LEWIS HARGETT CIR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3590
Practice Address - Country:US
Practice Address - Phone:859-268-1030
Practice Address - Fax:859-269-4120
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2015-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3003248367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74002247Medicaid
KY0985309Medicare PIN