Provider Demographics
NPI:1467606293
Name:HUMPHRIES, REBECCA FONDREN (APRN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:FONDREN
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 SMITH STREET
Mailing Address - Street 2:EMORY CLARK HOLDER CLINIC
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240
Mailing Address - Country:US
Mailing Address - Phone:706-882-8831
Mailing Address - Fax:706-812-4091
Practice Address - Street 1:303 SMITH STREET
Practice Address - Street 2:EMORY CLARK HOLDER CLINIC
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240
Practice Address - Country:US
Practice Address - Phone:706-882-8831
Practice Address - Fax:706-812-4091
Is Sole Proprietor?:No
Enumeration Date:2008-11-06
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN175845 NP363L00000X, 363LA2200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care