Provider Demographics
NPI:1376162818
Name:MCCONNELL, REBECCA JOAN
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JOAN
Last Name:MCCONNELL
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 1:471-250 EMERSON DR
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-5777
Mailing Address - Country:US
Mailing Address - Phone:530-310-5058
Mailing Address - Fax:
Practice Address - Street 1:2875 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-4739
Practice Address - Country:US
Practice Address - Phone:530-257-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS024331183500000X
NV20405183500000X
CA82209183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist