Provider Demographics
NPI:1508913583
Name:GUANAJUATO, REBECCA R (NP-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:R
Last Name:GUANAJUATO
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1115 RONALD REAGAN PKWY
Mailing Address - Street 2:SUITE 136
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-6910
Mailing Address - Country:US
Mailing Address - Phone:317-217-2900
Mailing Address - Fax:317-217-2909
Practice Address - Street 1:1115 RONALD REAGAN PKWY
Practice Address - Street 2:SUITE 136
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-6910
Practice Address - Country:US
Practice Address - Phone:317-217-2900
Practice Address - Fax:317-217-2909
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002250A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily