Provider Demographics
NPI:1417934324
Name:LUCILLE, REBECCA (APRN PSYCHIATRIC)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:
Last Name:LUCILLE
Suffix:
Gender:F
Credentials:APRN PSYCHIATRIC
Other - Prefix:MS
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN PSYCHIATRIC
Mailing Address - Street 1:337 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-1633
Mailing Address - Country:US
Mailing Address - Phone:801-633-5458
Mailing Address - Fax:
Practice Address - Street 1:5965 S 900 E
Practice Address - Street 2:SUITE 240
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-1720
Practice Address - Country:US
Practice Address - Phone:801-263-7225
Practice Address - Fax:201-263-7279
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3423224405364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult