Provider Demographics
NPI:1487642930
Name:LORRAINE, REBECCA LEIGH (ARNP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LEIGH
Last Name:LORRAINE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2839 LAKE MICHAELA BLVD
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-7955
Mailing Address - Country:US
Mailing Address - Phone:813-662-0123
Mailing Address - Fax:
Practice Address - Street 1:2237 LITHIA CENTER LN
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33594-5676
Practice Address - Country:US
Practice Address - Phone:813-662-0123
Practice Address - Fax:813-662-9422
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN1679372363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRN1679372OtherLICENSE
FLRN1679372OtherLICENSE
FLE3154YMedicare ID - Type Unspecified