Provider Demographics
NPI:1407491202
Name:SOURS, REBECCA MARIA BETTY
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARIA BETTY
Last Name:SOURS
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 1:9292.5 COUNTY ROAD 12
Mailing Address - Street 2:
Mailing Address - City:ANTONITO
Mailing Address - State:CO
Mailing Address - Zip Code:81120
Mailing Address - Country:US
Mailing Address - Phone:719-580-4309
Mailing Address - Fax:
Practice Address - Street 1:2115 STUART AVE
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2269
Practice Address - Country:US
Practice Address - Phone:719-589-8008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0995158-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily