Provider Demographics
NPI:1528606381
Name:MARIS, REBECCA R (LVN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:R
Last Name:MARIS
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7710 W INTERSTATE 10
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-4711
Mailing Address - Country:US
Mailing Address - Phone:210-377-3355
Mailing Address - Fax:
Practice Address - Street 1:7710 W INTERSTATE 10
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-4711
Practice Address - Country:US
Practice Address - Phone:210-377-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX203992164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse