Provider Demographics
NPI:1487844940
Name:BREM, REBECCA SUE (FNP, MSN)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:SUE
Last Name:BREM
Suffix:
Gender:F
Credentials:FNP, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 BRONCO CIR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3901
Mailing Address - Country:US
Mailing Address - Phone:541-941-6054
Mailing Address - Fax:
Practice Address - Street 1:502 BRONCO CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3901
Practice Address - Country:US
Practice Address - Phone:541-941-6054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200540819RN163W00000X
OR200550052NP FNP-PP363LF0000X
FL9312155363LF0000X
AL1-051629163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALP81523Medicare UPIN
AL000046978Medicare PIN
ALS10273Medicare UPIN
AL051553224Medicare PIN