Provider Demographics
NPI:1639504962
Name:WAHLGREN, REBECCA ELAINE (NP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ELAINE
Last Name:WAHLGREN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 APPIAN WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2565
Mailing Address - Country:US
Mailing Address - Phone:510-724-9110
Mailing Address - Fax:
Practice Address - Street 1:2160 APPIAN WAY STE 200
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2565
Practice Address - Country:US
Practice Address - Phone:510-724-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23606363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health