Provider Demographics
NPI:1629451190
Name:THEISE, REBECCA ALIZA (APRN)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:ALIZA
Last Name:THEISE
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 1:3911 N CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-1733
Mailing Address - Country:US
Mailing Address - Phone:917-613-0606
Mailing Address - Fax:
Practice Address - Street 1:1645 LIBERTY RD STE 205
Practice Address - Street 2:
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6542
Practice Address - Country:US
Practice Address - Phone:203-481-7008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-02
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR226346363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics